By Alicair Peltonen
I think a crucial step in decreasing the stigma surrounding mental illness is talking about it openly. And it seems readers want to talk.
My post, “The Medicated Woman: A Pill To Feel Better, Not Squelch Feelings” on mental health and medication was shared on Facebook more than 15,000 times and now has over 200 comments, so I thought it was worth a follow-up.
One thing readers wanted to discuss is the safety of antidepressants during pregnancy — a complicated topic which has been covered here and here on CommonHealth. Safety studies are mixed in many cases so women should consult their doctors. Here’s what it says on the Mayo Clinic website:
“A decision to use antidepressants during pregnancy is based on the balance between risks and benefits. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is very low. Still, few medications have been proved safe without question during pregnancy, and some types of antidepressants have been associated with health problems in babies.”
Other comments underscored that stigma still exists but may be slowly diminishing.
Jackie wrote: “It took me until I was in my 50’s to accept that medication wasn’t the “weak” way. I now see how much I lost and am living through a tremendously stressful life without those urges to accelerate into other cars or cement walls.”
“It’s in our family, but I was the first to seek help, and was probably the worst off. It was a secret that my grandfather had committed suicide,” wrote lilycarol.
And here’s a comment from helentroy4: “My mother was much like me. But to her dying day she never acknowledged that her behaviors were anything but ‘perfect mothering.’ I think had she been able to take advantage of this medication (or others of its kind), she would have been able to have the calming of her heart and soul that I have been blessed to have.”
There were many who suggested that lifestyle changes, including more exercise and sleep, meditation or yoga might be safer and more beneficial than medication.
I couldn’t agree more. But some thoughtful commenters responded with reminders that those things are difficult to accomplish in the throws of depression and anxiety.
Jennifer said it best when she wrote, “Pills won’t “fix” someone without lifestyle changes and self-examination. However, while some people can pick themselves up out of a depressive episode with just good self-care, maybe because they have the resources to do so, other people need aid to even get to that point. We need to remember that everyone is different.”
I wrote my article in response to the idea that women in particular are having their gender-specific feelings medicated away. But some comments from men reminded me that depression and anxiety show no gender-bias.
Diogenes wrote, “Despite many discussions with doctors these past 10+ years, the expectation for men is vastly different. We are somehow expected to cope without medication.”
I am so glad to have sparked this conversation. Whether or not you believe that medication is the answer, an answer, or no answer, the important thing is that we keep talking about it and keep asking for help, wherever we can get it.
Alicair Peltonen is a part-time administrative assistant at the Harvard School of Public Health and a journalism student at the Harvard Extension School.
The National Institute of Mental Health unveiled a five-year strategic plan emphasizing research it hopes will ultimately give clinicians a better understanding of what mental illness looks like inside the brain — before a patient shows outward symptoms.
NIMH is part of the National Institutes of Health.
The plan signals investment to figure out the genes associated with mental illness, develop new treatments based on those findings, make sure research findings are eventually implemented into practice and find brain patterns for a range of disorders.
These four objectives form a broad roadmap – part of what NIMH director Thomas R. Insel, M.D., describes as a “path to discover” – beginning with the fundamental science of the brain and behavior, and ending with public health impact. An estimated 9.6 million Americans have a serious mental illness that impairs daily functioning.
One of the hopes is that the research will enable health professionals to identify people who are at risk and begin treatment early in the disease process.This KHN story can be republished for free (details).
“Just as brain tumors are detected through CAT scans and diabetes is diagnosed through blood sugar testing, NIMH is focused on employing brain imaging to detect common mental disorders and severe mental illnesses before full-blown clinical presentation,” said Al Guida, the president of Guide Consulting Services, a Washington-based government relations firm that specializes in behavioral health.
Early diagnosis would make a big difference on a variety of levels, allowing people to finish school, find jobs and lead more productive lives.
Shelli Avenevoli, chief of NIH’s Developmental Trajectories of Mental Disorders Branch, says NIH already has research going on that seeks to get help for people right after their first psychotic break. The trial results have been so promising that Congress required each state, starting last year, to implement a program based on the findings.
“For those of us in this area, it’s an aspirational goal: to identify those at risk as early as possible and hopefully before onset of full syndrome so that we can then not just treat something, but prevent it,” Avenevoli said.
But even with private and public research investment, it could be decades before the scientific advances are applied so that a child could be screened for mental illness with a CT scan or some other such tool, said Paul Gionfriddo, president and CEO of patient advocacy group Mental Health America. He added, though, that science already shows that early signs of mental health problems — sleep problems, unusual risk taking, disorganization and difficulty forming friendships — need to be taken into account when diagnosing mental illness.
“Long before the first psychotic break, these symptoms worsen over time and affect school success, relationships with siblings and parents, and inclination to self-medicate,” Gionfriddo said. “We didn’t wait until we had a cure for cancer before doing early identification and starting to fight it, and we can’t afford to wait until we have a cure for psychosis before fighting that either.”
Shifting resources from treating people when they have a full-blown illness to when they are just presenting symptoms or have an irregular brain scan will mean a change in how the mental health system works, said Ken Duckworth, medical director for patient advocacy and lobbying group the National Alliance for Mental Illness. “NIMH is helping to drive a culture change,” he added.
But despite the promise, some experts also offer reminders that even with such advances there will still be room for error.
“They’re looking for a perfect indicator before intervention, but is anyone noticing what’s going on with mammograms and other imperfect early indicators that work well enough, but have flaws? Elevated cholesterol levels don’t necessarily mean you’ll have a heart attack,” and the same will be true for mental illness, said William McFarlane, director at the Center for Psychiatric Research at the Maine Medical Center in Portland, Maine.
Whether a patient is in the hospital for an organ transplant, an appendectomy or to have a baby, one complaint is common: the gown.
You know the one. It might as well have been stitched together with paper towels and duct tape, and it usually leaves the wearer’s behind hanging out.
“You’re at the hospital because something’s wrong with you – you’re vulnerable – then you get to wear the most vulnerable garment ever invented to make the whole experience that much worse,” said Ted Streuli, who lives in Edmond, Okla., and has had to wear hospital gowns on multiple occasions.
Put another way: “They are horrible. They are demeaning. They are belittling. They are disempowering,” said Camilla McRory of Olney, Md.
The gowns are among the most vexing parts of being in the hospital. But if efforts by some health systems are an indicator, the design may be on its way out of style.
The Cleveland Clinic was an early trendsetter. In 2010, it introduced new gowns after being prompted by the CEO, who often heard patient complaints when he was a practicing heart surgeon. That feedback led to a search for something new, said Adrienne Boissy, chief experience officer at the hospital system.
The prominent academic medical center ultimately sought the help of fashion icon Diane von Furstenberg, settling on a reversible gown with a front and back V-neck, complete derriere coverage, and features such as pockets, softer fabric and a new bolder print pattern.
Patients “loved the gowns,” Boissy said. “People felt much more comfortable in the new design, not just physically but emotionally.” In recent years, she added, “hospitals are looking at everything they do and trying to evaluate whether or not it contributes to enhancing the patient experience.”This KHN story also ran in The Washington Post. It can be republished for free (details).
It’s all part of a trend among hospitals to improve the patient reviews and their own bottom lines – fueled in part by the health law’s focus on quality of care and other federal initiatives. The Centers for Medicare & Medicaid Services increasingly factors patients’ satisfaction into its quality measures, which are linked to the size of Medicare payments hospitals get.
Sometimes the efforts involve large capital improvement projects. But they can also mean making waiting rooms more comfortable, improving the quality of food served to patients or, as in this case, updating hospital gowns.
Ultimately, this focus leads to “a better patient experience,” said John Combes, senior vice president of the American Hospital Association.Hospital Couture
Whether in the movies or real life, even celebrities have had to struggle with the indignities of hospital gowns, also known as Johnnies. Here is what we are sure they were thinking in some of these memorable moments:
The Detroit-based Henry Ford Health System is in the process of updating its gowns, an initiative that began when the system’s innovation institute challenged students at the city’s College for Creative Studies to identify and offer a solution to one hospital problem.
The students responded with the suggestion to redo the garment that has often been described by patients as flimsy, humiliating, indecent and itchy. The process took three years, but last fall, the institute unveiled a new and improved version. It’s made of warmer fabric – a cotton blend – that wraps around a patient’s body like a robe and comes in navy and light blue, the hospital’s signature colors.
Patient expectations are part of the calculus. They “are demanding more privacy and more dignity,” said Michael Forbes, a product designer at the Henry Ford Innovation Institute.
I could probably communicate more confidently with medical providers if I didn’t start the visit feeling unable to dress myself.- Paula Fleming, Minneapolis, Minn.
When the institute tested his gown design, Forbes said, patient-satisfaction scores noticeably increased in a few days.
The new gown “was emblematic … of an attitude that was conveyed to me at the hospital – that they cared about me as a whole human being, not just the part they were operating on,” said Dale Milford, who received a liver transplant during the time the redesign was being tested. “That was the subtext of that whole thing, was that they were caring about me as a person and what it meant for me to be comfortable.”
But replacing the traditional design is no easy task. What patients wear needs to be comfortable yet allow health professionals proper access during exams, meaning it must open and close easily. The gowns also need to be easily mass-manufactured, as well as efficiently laundered and reused.Hospital gowns: Time for a change?
Patients have little good to say about the traditional hospital gown. Here’s what several told KHN:
- “This is the most humiliating thing about being in the hospital. … I was hospitalized for appendix surgery when I was 12, and now am 70 and the gown remains the same.”
– Jeff Gordon, Washington, D.C.
- “It is difficult to put on, hard to fasten, and doesn’t provide the ready access the doctors want. Why are we still doing this?”
– Josie Scott, Livonia, Mich.
- “I have often been asked to don such a gown and then to walk around, sometimes past large numbers of people, wearing these contraptions. … I hate it.”
– William Mouser, Waxahachie, Texas
- “Either issue real bed wear or do away with them completely. I can always wrap a sheet around me. … It is a ridiculous garment that serves little purpose other than expose my backside.”
– Steven Shephard, Colorado Springs, Colo.
New designs, though, can be expensive. After Valley Hospital of Ridgewood, N.J., switched to pajamas and gowns that provide extra coverage, costs went up $70,000 per year, said Leonard Guglielmo, the facility’s chief supply chain officer, because the new garments cost more to buy and maintain.
Beyond cost, more ingrained cultural expectations might also play a role in what hospitals think patients should wear, said Todd Lee, an assistant professor of medicine at McGill University, who co-authored a 2014 study in the journal JAMA Internal Medicine, examining whether gowns were important and whether patients might be fine wearing their own or hospital-provided pants, instead of or along with gowns.
Often, doctors reported that pants or undergarments beneath gowns would have been okay, but patients said they were never given those options. Traditional gowns make it easier to examine patients quickly, and several doctors Lee spoke to seemed shocked at the idea that patients might wear garments other than the open-backed gown during their stay.
But the most common challenge isn’t necessarily doctor expectations or costs. It’s navigating hospital bureaucracies, said Dusty Eber, president of the California-based company PatientStyle, which designs and sells alternative gowns. In his company’s experience, hospital decisions are often made by committees, not individuals.
“There’s a lot of bureaucratic runaround,” Eber said.
Kairis Chiaji from Sacramento, California, says it was difficult to afford health insurance before the Affordable Care Act on her self-employed income as a birth coach. The 43-year-old was excited when she heard about the ACA, but experienced a mix up with her application through Covered California that delayed her enrollment.
The baseball season starts next week, but in other parts of the world the focus over the last six weeks has been on that other sport involving bat and ball: cricket. I wonder how many people in the U.S. have, like me, watched some of the Cricket World Cup matches. Potentially quite a few, given that there are many people living here who might identify with some fairly cricket-mad countries, including about three million Indian-Americans, over three hundred thousand Pakistani-Americans, and about two and a half million people of West Indian or Caribbean heritage. Worldwide, the expected television viewing audience for the four-yearly event was a billion people. In fact, the India vs Pakistan match early in the tournament was predicted to set a record with more than a billion viewers.
The final of the fourteen-team World Cup, the eleventh such tournament, took place over the weekend in Melbourne, Australia. Australia beat New Zealand to win the cup for the fifth time. (New Zealand may have a chance for revenge later this year during the Rugby World Cup tournament being played in England, where the All Blacks will seek to retain the trophy.)
In honor of the completion of the Cricket World Cup, I thought I’d share some law-related tidbits from the cricketing world. To begin with, the official cricket rules are actually called the “Laws of Cricket.” They even have a preamble that refers to the “Spirit of the Game” (yes, with capitals), as well as a preface, the laws themselves, and appendices. The Laws are supplemented by the “playing conditions” set by the International Cricket Council (ICC) that apply to specific formats or tournaments, while each country also sets their own playing conditions for domestic competitions. So I guess you could say that fully understanding the rules of cricket involves something of a statutory interpretation exercise!
The World Cup and TV in India
One very recent case that relates to cricket comes out of India; unsurprisingly, perhaps, since cricket is by far the most popular sport in that country. Whenever the national team plays, an estimated four hundred million people in India watch and there are more cricket players in India than in the rest of the world put together. This provides some context for the case, in which the Guhawati High Court found in favor of the plaintiffs, a group of seven remand prisoners, who had argued that watching the 2015 Cricket World Cup was part of their “right to life and personal liberty” under article 21 of the Indian Constitution. The judge ordered that the prison make cable television available within five days, ruling that “prisoners need recreation for a healthy mind.”
While the Indian team’s matches are being shown for free in India, the rest of the matches are only available on a subscription-based cable network, which holds the official rights to show the tournament in India. In fact, only a few weeks prior to the above case, the Supreme Court of India had ruled that the public broadcaster could share live feeds of the Indian team’s World Cup matches, enabling those matches (and the semifinals and final) to be shown free of charge. The public broadcaster’s argument had included the fact that section 3 of the Sports Broadcasting Signals (Mandatory Sharing with Prasar Bharati) Act, 2007, specifies that content rights holders and television broadcasting service providers must share the live broadcasting signal of “sporting events of national importance” with the public broadcaster “on such terms and conditions as may be specified.”
Other legal wranglings in recent years have unfortunately involved more negative developments for cricket fans. In addition to being one of the most-watched sports in the world, cricket is also among the sports with the most betting activity. In the past few years, there have been several scandals and investigations related to match-fixing, resulting in player bans and some criminal prosecutions. In addition to the roles of the ICC and domestic cricket bodies in this area, some countries are also seeking to address aspects of the issue (that of course go beyond cricket into other sports) through legislation and other actions. For example, the UK government recently released a cross-government Anti-Corruption Plan that includes a dedicated section on sports betting integrity and match-fixing. In New Zealand, the government introduced specific amendments to the Crimes Act 1961 through the Crimes (Match-fixing) Amendment Bill, which was enacted in December 2014.
Kerry Packer and World Series Cricket
Going back a bit further into the legal history surrounding cricket, there emerged a much-publicized and controversial case in the late 1970s when Australian media magnate Kerry Packer established a breakaway cricket tournament called World Series Cricket (WSC), after his bid to gain television rights to Test matches (full length matches between national representative teams) was denied by the Australian Cricket Board. His approach involved secret signings of a number of players from around the world, and the international cricketing establishment reacted with outrage and confusion once the news broke. The ICC subsequently ruled that any players taking part in Packer’s tournament would be banned from playing in Test matches, meaning that their international careers would effectively be over. The English cricket board made a similar ruling with respect to county cricket. These rulings led to a court case in England brought by three WSC players, backed by Packer, that lasted for seven weeks. In a significant, 211-page decision, the High Court ruled against the ICC for restraint of trade, finding that, by imposing the restrictions, the cricket bodies had acted to induce players to breach their contracts with WSC.
The WSC tournament only lasted for two seasons between 1977 and 1979, at which point Packer’s station won the broadcasting rights for Australian cricket as well as a promotional contract, but it had a lasting impact on the game. The impacts were seen in the professionalization of cricket, player contracts and salaries, how cricket is televised and marketed, and even the different colored uniforms. It also paved the way for the development of other independent tournaments, such as the current Indian Premier League. Greg Chappell, a famous Australian cricketer who captained one of the WSC teams, has said that Packer’s tournament “dragged the game of cricket kicking and screaming into the 20th century.” Several books have been written about the WSC and the surrounding controversy. A two-part miniseries about Packer and the WSC aired in Australia in 2012, and in the UK in 2013. You will also find the court case referred to in legal texts, on sport, employment, contract, and tort law.
Lord Denning in Miller v Jackson
Also in the 1970s, English judge Lord Denning wrote one of his most famous judgments in a case that involved a dispute over cricket balls being hit out of a village cricket ground onto a neighboring property. The neighbors, who brought claims of nuisance and negligence, failed to gain an injunction against the cricket club, but were awarded damages for the repeated interference with their property and for negligent damage for each time it was hit by a ball. The majority in the Court of Appeal of England and Wales held that the fact that the Millers had “come to the nuisance” was no defense. However, the Court did not think it would be fair to stop play altogether. Geoffrey Lane LJ stated that the Court
must seek to strike a fair balance between the right of the Plaintiffs to have quiet enjoyment of their house and garden without exposure to cricket balls occasionally falling like thunderbolts from the heavens, and the opportunity of the inhabitants of the village in which they live to continue to enjoy the manly sport which constitutes a summer recreation for adults and young persons, including one would hope and expect the plaintiffs’ son.
Lord Denning had a bit of a different take on things, extolling the virtues of cricket as a social activity in a dissenting judgment that I have seen described as “one of the more whimsical passages in the annals of the game.” Law students in Commonwealth countries will I’m sure be familiar with the wording from their torts law classes, but perhaps other readers haven’t had the chance. So, in honor of the approaching summer days, whether they involve cricket or baseball or other relaxing outdoor activities, here is the opening wording of Lord Denning’s decision:
In summertime village cricket is the delight of everyone. Nearly every village has its own cricket field where the young men play and the old men watch. In the village of Lintz in County Durham they have their own ground, where they have played these last seventy years. They tend it well. The wicket area is well rolled and mown. The outfield is kept short. It has a good club-house for the players and seats for the onlookers. The village team play there on Saturdays and Sundays. They belong to a league, competing with the neighbouring villages. On other evenings after work they practice while the light lasts. Yet now after these 70 years a Judge of the High Court has ordered that they must not play there anymore. He has issued an injunction to stop them. He has done it at the instance of a newcomer who is no lover of cricket. This newcomer has built, or has had built for him, a house on the edge of the cricket ground which four years ago was a field where cattle grazed. The animals did not mind the cricket. But now this adjoining field has been turned into a housing estate. The newcomer bought one of the houses on the edge of the cricket ground. No doubt the open space was a selling point. Now he complains that, when a batsman hits a six, the ball has been known to land in his garden or on or near his house. His wife has got so upset about it that they always go out at weekends. They do not go into the garden when cricket is being played. They say that this is intolerable. So they asked the Judge to stop the cricket being played. And the Judge, I am sorry to say, feels that the cricket must be stopped: with the consequences, I suppose, that the Lintz cricket-club will disappear. The cricket ground will be turned to some other use. I expect for more houses or a factory. The young men will turn to other things instead of cricket. The whole village will be much the poorer. And all this because of a newcomer who has just bought a house there next to the cricket ground.
These are really just a sample of the legal cases that relate to cricket in some way. You can find various other writings on this topic, including in a 2014 book titled “Court and Bowled: Tales of Cricket and the Law.”
If you went on a little T ride with Dr. Sandro Galea, the new dean of the Boston University School of Public Health, the urban landscape would never look quite the same to you, I bet. You wouldn’t just see neighborhoods, anymore; you would see health neighborhoods.
In his latest “Dean’s Note” post, Dr. Galea uses images like the one above to illustrate the yawning gaps in health statistics among Boston’s neighborhoods. (Get off at Dudley Square, the diabetes rate is 11 percent; get off at Arlington, it’s just 3 percent.) He also posts T-stop numbers on low birth weight, physical activity and homicide, among other health-related stats. And he writes:
Inured as we are to inequalities in health, we might well shrug off these health differences as ones between far-apart worlds. But are they? In fact, the geographic space we are talking about here is remarkably small. We are dealing with geographic differences of roughly four miles, or about an hour’s walk. In many respects, it is remarkable that areas so close to one another should have such dramatically different health indicators—“health worlds apart” that are simply down the street from one another.
Those health worlds may be far apart indeed. A new “Child Opportunity Index” suggests that Boston may be the worst city in the country for Hispanic kids in terms of healthy development.
Developed by researchers at Brandeis University’s Heller School for Social Policy and Management and Ohio State University’s Kirwan Institute for the Study of Race and Ethnicity, the index finds that 58 percent of Hispanic children in Boston live in neighborhoods with the lowest level of access to “healthy development resources,” from parks to high-quality child care.
The index also found Boston to be the sixth-worst metro area in the country for African-American children.
From the press release, headlined, “Boston has the Highest Concentration Nationally of Hispanic Children Living in the Worst Neighborhoods for Healthy Development:”
When it comes to healthy development resources, not all of Boston neighborhoods are equal — and the areas with the lowest level of access are typically home to the city’s minority children. 57.6 percent of Hispanic children in the Boston metro area—the highest percentage in the country—live in neighborhoods that have the least access to healthy development resources, according to the newly developed Child Opportunity Index.
Boston is also ranked the sixth-worst metro area for black children’s healthy development, with 57.8 percent living in the lowest opportunity neighborhoods. Conversely, just 9 percent of Boston’s white children live in the lowest opportunity neighborhoods. A graphic summary of Boston’s numbers is available here.
“Previously, studies have looked at neighborhood conditions in one or a few areas. This is the first time data on neighborhood resources that matter for children—and where children of different racial and ethnic groups live in relation to those resources—is available for the 100 largest metro areas,” says lead researcher Dr. Dolores Acevedo-Garcia of the Heller School’s Institute for Child, Youth, and Family Policy.
The index shows considerable variation across America. For example, the proportion of Hispanic children living in very low opportunity neighborhoods ranges from about 10 percent in New Orleans to the aforementioned 57 percent in Boston. In Albany, 60 percent of the area’s black children live in its lowest opportunity neighborhoods, compared to McAllen, Texas, which is the best at 8 percent.
The release notes that pediatricians at Boston Medical Center are using the index along with medical records to try to understand how neighborhood conditions affect health issues, including obesity and asthma.
The Boston numbers, in graphic form below, are part of the Heller School’s diversitydatakids.org project, which aims to use data to help reduce inequality in child health.
Readers, thoughts? New sense of the city?