By Nell Lake
Are we over-treating the elderly with psychiatric drugs?
That’s the natural question arising from a recent report that found adults over 65 are receiving psychotropic medications at twice the rate of younger adults. The study, published in this month’s Journal of the American Geriatrics Society, also found that elders are much less likely to get their mental health care from psychiatrists or to receive psychotherapy.
What’s the problem? First, psychotropic drugs generally pose greater risks to the elderly than they do to younger patients, and non-drug approaches, from therapy to meditation, may be as effective as psychotropic medications for some seniors’ mental disorders, without the risks.
The findings suggest that physicians and insurers should reassess psychotropic drug use among the elderly, says lead author Donovan Maust, a geriatric psychiatrist and assistant professor of psychiatry at the University of Michigan.
Maust’s team used 2007-2010 data from the CDC’s National Ambulatory Medical Care Survey and from the U.S. Census to compare the rates at which older and younger adults — those 65 and older, and those 18-64 — get prescribed psychotropic medications during outpatient doctors’ visits. After analyzing more than 100,000 of these doctor visits, and taking into account the fact that the younger population is much larger than the older one, the researchers found that older adults were much more likely to be prescribed psychiatric drugs for anxiety, depression and other mental health conditions. Researchers also found that these seniors were less likely to receive other types of non-drug treatment for their mental distress.
The importance of all this is fairly clear: The elderly population is booming, and seniors use the health care system more than any other demographic. So, finding safe, effective and appropriate treatments for their mental health problems has an impact — for the well-being of a large swath of people, and as a policy matter.
Too Many Meds, And The Wrong Kind?
Psychotropic drugs pose both direct and indirect risks to the elderly: First, the drugs themselves can be dangerous. The American Geriatrics Society lists many psychotropic medications as potentially inappropriate for elderly patients.
“Probably the clearest concerns would be in the anxiolytic [drug] group,” in particular, anti-anxiety medications, like Ativan and Xanax, Maust says. Evidence suggests that these medications increase the risk of falls in older adults, which can cause a cascade of problems — from fracture to hospitalization to surgery and even increased risk of death. Anti-anxiety medications may double the risk of motor vehicle accidents. Recent research also shows a possible increased risk of dementia if the drugs are used long term.
Antidepressants, while somewhat safer than anti-anxiety meds, may increase blood pressure and, Maust says, “medicines that work on serotonin can increase bleeding risk — very slightly. But in an older adult who’s also taking [blood thinners] like aspirin or Coumadin,” this risk should be a concern.
A more basic, practical worry is that of loading patients — often already on multiple medications — with yet another drug to keep track of: “These patients can be on 10, 12 medications,” Maust says. “Even if the [psychiatric] medication doesn’t have side effects or otherwise cause trouble, adding one more medication — increasing the complexity of the regimen — increases the potential of getting things mixed up.” An elderly patient might take the wrong dose, forget doses or mix up the order in which drugs should be taken.
Add to this the issue of dementia: more common, of course, among people over 65. “It’s very common that a person with dementia might have depression or anxiety, so use of these medications might be appropriate,” Maust says. But studies have shown that the benefits are often minimal. And “in general if someone’s brain isn’t functioning at a 100 percent,” he says, “I would worry about adding a medication that… affects the brain.”
Young Vs. Old
The study’s main finding — this stark difference in the rate of psychiatric drugs — could be the result, Maust says, of an over-correction. In recent decades, health care providers have worried that the elderly aren’t receiving enough treatment of mental disorders. The effort has been focused on making sure doctors recognize depression and anxiety when they’re present. So physicians and insurers have instituted more screening in primary care.
But the pendulum may have swung too far, and because the drugs are often the easiest treatment to turn to, depressive and anxious symptoms may now too often get treated with drugs.
The “newer” antidepressants — think Zoloft and Prozac — are easier to use than the drugs of decades ago, and have fewer side effects. Part of what’s driving the rise of these treatments is that “they’re perceived to be safer,” Maust says. “By and large that really is true,” he says, but doctors should proceed with caution.
Another likely reason for the disparity is oddly circumstantial, a question of exposure — to doctors. Older people are more likely to be in contact with the people who do the prescribing. Because they often face complex health problems, seniors tend to see their doctors more often than younger people do. So an elderly man, for example, who goes often to his doctor for management of his multiple chronic conditions, such as diabetes, high blood pressure, arthritis, might complain one day that he’s feeling distress. His wife has died, and he’s more housebound than ever. His doctor sees symptoms of depression, and considers what course to take.
“Ultimately,” Maust says, “physicians sort of do what they know best. For a lot of people, that’s prescribing. Something like Zoloft seems pretty safe. You hope that it will help your patient.”
This patient’s doctor might suggest what’s readily at hand: She prescribes the antidepressant.
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Reimbursement systems also reinforce the use of psychiatric drugs. Physicians, Maust says, might want to refer a patient to therapy, or to send their patient down the hall to talk with a social worker. “But they might not have those resources available to them,” Maust says, adding that insurers often gear reimbursements toward prescribing medications rather than toward non-drug approaches.
“I do think providers are trying to help their patients. But we know that a lot of times for mild or even moderate depression and anxiety, a ‘watchful waiting’ approach often works, and symptoms will improve on their own without the medication.”
Psychotherapy can also be helpful. But sometimes, with drugs readily available, a physician starts a medication, a patient shows improvement, “and then [the physician is] reluctant to stop it and [the patient is] on the medication indefinitely.”
“It’s a time to think about whether there might need to be a little bit of a course correction,” Maust says. He recommends renewed restraint in prescribing psychotropic drugs, and support for alternatives to medication when appropriate — for psychotherapy, for the help of social workers, for a “wait and watch” approach.
Others agree. There’s renewed interest in a medical model called collaborative care, one of the approaches gaining ground through health care reform and the Affordable Care Act. The primary care physician gets support from a team — including, usually, a nurse manager, a consulting psychiatrist, a social worker — who coordinate care for patients with anxiety, depression and other chronic conditions. The team might decide to take a “wait and watch” approach, monitoring symptoms. A social worker might counsel patients in cognitive and behavioral strategies. A psychiatrist might provide advice about reasons to avoid certain medications. Through such collaborative care, physicians have more support in considering alternatives to drugs.
Asked if, in some cases, such alternatives might include activities to elevate elderly patients’ moods, Maust was cautious. No one is suggesting that an art class, for instance, will totally cure depression. Maust wants to be clear: Medications are important and appropriate care in many cases. “But for some of these [elderly] people,” he adds, “an art class might work pretty well.”
Nell Lake, a journalist and magazine writer, wrote the book, “The Caregivers: A Support Group’s Stories of Slow Loss, Courage And Love,” in which she chronicles the lives of family caregivers over two years. She lives in western Massachusetts.
On Tuesday, July 21, I had the delightful, albeit hot and humid experience, of enjoying a night out with my colleagues and our 2015 summer interns at Nationals Park to watch the Washington Nationals play against the New York Mets. If you have been following In Custodia Legis, it probably does not come as a surprise that we attended a game after work since many of my colleagues have expressed their passion for the national pastime on this blog. For those readers who may have missed it, you can check out my colleague Betty Lupinacci’s posts, Opening Day and the Law and Baseball and the Law, which highlights what is in the Law Library’s collection related to baseball and Baseball Americana, an exhibit held at Nationals Park which highlights the Library’s vast baseball collections.
Today’s picture captures the moment when our attendance at last week’s game was announced on the Nationals Park scoreboard; of course this ten second moment was accompanied by enthusiastic cheers and claps from me and my colleagues.
In case you are wondering, the Nats did not win the game, but we won a delightful opportunity to spend time together outside of work and eat hot dogs and countless peanuts, so I would consider it a winning night!
For end users, Windows 10 introduces a new Start menu, web browser, personal digital assistant, and more. For IT admins, the latest version of Windows includes features like Azure Active Directory support and Windows Update for Business.
If there’s such a thing as the first family of health care, the Lees may be it.
Five decades ago, two brothers helped start Medicare. Their father inspired them and they, in turn, have inspired the next generation.
To mark the anniversary of President Lyndon Johnson signing Medicare into law on July 30, 1965, three Lees sat down to reflect on the U.S. health care system.
It can be hard now to imagine a time when Medicare met serious opposition. But 92-year-old Dr. Peter Lee, a founder of the family medicine department at the University of Southern California, remembers that time well.Related Stories
Marking a Milestone
“I was one of the people who was supporting the idea,” he says. “And in response to that some people from the USC alumni association wanted me fired because they thought that was socialized medicine.”
The Los Angeles County Medical Association, too, called for Lee’s ouster. While Lee didn’t get fired, he did get called a lot of names. The same thing happened to his now 91-year-old brother, Dr. Phillip Lee, who helped implement Medicare in the Johnson administration.
“They called me a socialist more often than a communist, but occasionally they referred to me as a communist,” he recalls.
Among those who did that, he says, was former President Ronald Reagan, who lent his voice to an ad by one of Medicare’s biggest opponents, the American Medical Association.
“One of the traditional methods of imposing state-ism or socialism on a people has been by way of medicine,” Reagan says in the ad.
The AMA opposed Medicare out of fear the government would become too deeply involved in the practice of medicine. But that didn’t sway the Lee brothers. Their work as ardent foot soldiers for Medicare, was borne in part from family legacy of health policy started by their father, Dr. Russell Lee, says his grandson Peter Lee.This story is part of a partnership that includes KPCC, NPR and Kaiser Health News. It can be republished for free. (details)
“One of the things my grandfather did was he was involved in the Truman Commission, which in the 40s was one of the early reports generated to say we need national health care,” says the younger Peter Lee.
He went into the family business when he became a health policy expert. And he now runs Covered California, overseeing the largest expansion of insurance coverage in California since Medicare. His father, the elder Peter Lee, says the passage of Medicare changed the game. Before the law, the medical center where he worked was overflowing with elderly patients who had been discharged but needed some interim care before going home.
“So we always had patients in the hall,” he says. “Then Medicare was passed and then the halls were all empty.”
His son, Peter, explains, “They were empty because seniors all of a sudden had someone that would pay for long-term care that wasn’t there before. And it was a dramatic overnight change that affected millions of Americans.”
That’s because Medicare paid for, transitional nursing home care and other treatments for those 65 and older, no matter their income. Today Medicare provides health care for nearly every American 65 and older.
And the law prompted something else: the desegregation of hospitals. Among those at the front line of that battle, the elder Peter Lee’s brother, Philip.
“Desegregation was critical,” says Philip Lee. “You couldn’t have a segregated medical care system.”
Philip Lee was sent to the South to make sure hospitals didn’t discriminate. He says it took the threatened loss of federal Medicare dollars to overcome resistance by many hospitals that ultimately integrated. And integration meant everyone and everything — from patients and staff all the way to the blood supply.
“And we made a lot of progress, even if it wasn’t perfect,” he says.
Today, both of the elder Lees say the biggest issues facing the nation’s health care system is making sure everyone gets medical care.
It’s a job that the younger Peter Lee says he’s taken on with inspiration from his family legacy and support from his father and uncle. And, he says, they set a high bar.
“It take persistence. It takes hard work. But change happens,” he says.
It seems like only yesterday we were running around Philadelphia for the annual conference of the American Association of Law Libraries. The week before the conference, Kelly wrote a post previewing the programs in which our staff would make presentations on subjects from content management, to the marketing of events, management of library internship programs, and the future of information policy.
On Tuesday morning, we presented “The Multi-Channel Event Marketing Cycle.” During the program, we promised to put our slides up and here they are. Jeanine reviewed the history of our programs and events, described how we refined our marketing techniques over the last five years, and showed our event marketing cycle.
Andrew illustrated the marketing cycle using the Magna Carta symposium from December last year. The cycle started with the press release; which led to the Facebook event; the In Custodia Legis blog post announcement; a Facebook post about the symposium with a link to the blog post; a tweet from @LawLibCongress (including the event hashtag, #1215MCLC); an RSS/email alert; and reminders leading up to the event. Next, Andrew showed how the event was live tweeted, recapped on this blog, and posted as a video on YouTube.
It is a tradition to survey staff who attended the conference and share our takeaways from various programs and events. Here are this year’s insights:
The annual meeting of the American Association of Law Libraries provides a wonderful opportunity to learn about current trends in the profession, re-connect with colleagues from around the world, and nurture new relationships. I attended several enlightening educational programs.
I found particularly interesting a program on “Net Neutrality and Law Librarians: It’s a Good Thing.” Christopher Dykes, O’Quinn Law Library, University of Houston Law Center, explained that network neutrality or “net neutrality” essentially means that no particular kind of content should receive priority over other types of content. He then provided a historical overview of related legislative and regulatory actions. Leslie Street, University of North Carolina at Chapel Hill, explained why law librarians should be concerned with the issue. She noted that librarians already have a tough time trying to both determine and promote authoritative sources on the web and their job becomes even more difficult in an environment of pay prioritization. “Libraries require an open internet,” she said. Finally, Daniel Donahue, also from O’Quinn Law Library, University of Houston Law Center, suggested several subscription and free alert services available to those interested in tracking the status of legislative, regulatory, and court activities related to net neutrality. I was happy to note that one of the free alert services he mentioned was Congress.gov.
This year at AALL I was delighted to celebrate the 75th anniversary of the University of Washington Law Librarianship Program. We honored Mary Hotchkiss for 20+ years of service to the program and Penny Hazelton for 30+ years as director of the program and as one of this year’s recipients of the Marian Gould Gallagher Distinguished Service Award.
My lessons learned include two programs that expanded my knowledge of what law librarianship is and does. I attended “Researching the European Union” with Ian Thomson from Cardiff University’s European Documentation Centre. It was an all-day event to understand the increasing amount of information from the European Union and where to locate that information online. I also attended a program on “databrarians,” which talked about how law librarians are increasingly being asked to focus their research on data, statistics, and empirical legal research services. I think it’s time to brush up on my mathematics skills!
The AALL annual meeting is a wonderful way to learn of new developments in law librarianship, exchange ideas about issues affecting law libraries, and connect with colleagues from across the country and around the world. My favorite session was one on empirical legal research entitled “So You’re a ‘Databrarian’ Now: Learning the Tools of the Trade.” The presenters, Sarah Ryan of the Yale Law School Library, Michelle Hudson of the Yale University Library, and Jon Ashley of the University of Virginia Law Library, described how to conduct effective data reference interviews, a roadmap of resources for data research, and empirical research project management. I also enjoyed a panel discussion entitled “Confronting the Future of Information Policy,” with the Superintendent of Documents at the Government Publishing Office Mary Alice Baish; Acting Director of the Office of Federal Register at the National Archives and Records Administration Amy Bunk; and our own Deputy Librarian of Congress David S. Mao. The panel discussed issues regarding collection of digital content and their agencies’ digital content strategies. Another highlight was visiting a number of exhibits by publishers and vendors at the conference, which is a great way to learn about new legal research publications, products, and technologies.
On Saturday I attended an all-day pre-conference workshop on “Researching the European Union,” presented by Ian Thomson, the director of the European Documentation Centre at the University of Cardiff. He provided a remarkably comprehensive presentation that covered the historical development of the EU, a description of the EU’s policymaking institutions, the EU’s legislative procedures, and a thorough demonstration of sources and techniques for researching and monitoring EU law and policy. He did a terrific job making the EU’s rather complicated institutional structure and processes understandable. Portions of the information presented in the program can be found on the European Sources Online website (of which Thomson is Executive Editor) in an Information Guide entitled “Europe on the Internet” (updated July 2015).
This year I really enjoyed two relatively new additions to the Annual Meeting: Poster Sessions in the Exhibit Hall and Coffee Talks.
The Coffee Talks are informal discussions, on select topics, with a host leading the discussion. They offered fifteen topics including, for example, mastering the Skype interview, law firm and academic law librarians discussing how to best prepare new associates, and platforms for communicating about vendor relations. I joined the table discussing leadership development and learned about many resources within AALL, including the Leadership Academy and the Mentoring Committee.
The Poster Sessions included 27 posters within six broad categories such as, Collection Development and Cataloging, Information Technology, and Reference, Research, and Client Services. You could browse the posters any time the Exhibit Hall was open and the presenters were available to respond to questions at a designated time. These posters were based on very practical experiences or issues that arose in a library. I wasn’t able to see all of the posters, but some highlights for me included a comparison of Lexis Advance and WestlawNext on accuracy and speed of search results, an analysis of the question of whether or not to continue participating in the Federal Depository Library Program, how to use crowdsourcing to select a new library logo, and how to improve search engine optimization of legal scholarship in open source repositories.
I attended a fascinating presentation about Watson, the IBM computer system that appeared on Jeopardy. This presentation focused on moving cognitive computing beyond trivia and into other fields such as medicine and the law. Currently, IBM’s Watson team is already working with doctors in hospitals throughout the country and they are working on trying to break into the legal profession. Audience participants expressed concern about confidential and proprietary information; however, Watson is not a single unit. Rather, each hospital, law firm, etc. has their own Watson computer system that starts with a blank slate and the doctors, nurses, and lawyers work with the system, and technicians, to feed it the information they deem important. As stated in the presentation, this has amazing potential because, with doctors and the lawyers already working 60 hours a week, it’s hard to find time to read all of the new articles in the field about new drugs, new diseases, and new case law. Well, they could simply give the Watson system all of the files and it would instantly search them for relevant data while the doctor or lawyer is doing more research.
I attended the conference on the Sunday only, but even in that short time came away with some new ideas! One of the sessions I attended was on using infographics for legal information. Here at the Law Library we’ve recently started using maps in some of our multinational reports to show countries that have certain or similar legal approaches to an issue. Sayuri’s report on the legal responses to the 2011 Japan earthquake also included some visual displays of information. Of course, there are many different ways that information can be displayed visually, and there are various tools available to help with this. The presenters at the session gave some great tips about creating infographics for legal information, showed lots of examples, and provided links to online tools. Definitely plenty to think about!
Also in the technology-related area, I attended a fun, informative session on free technologies for law libraries. The presenters may have inspired me to add different features into the various presentations that I give here at the Law Library on our foreign law research products, services, and expertise. Future visitors from law schools might even get a pop quiz or game on their smartphones, so be ready!
This was my first year volunteering for the CONELL (Conference for Newer Law Librarians) Marketplace. I staffed the Government Law Libraries Special Interest Section table with two federal colleagues, sharing a table with the Federal Law Librarian Caucus. Meeting new law librarians and first time attendees excited about the profession is always enriching and invaluable. The Cool Tools Café session I found to be quite amazing, with academic, private, and federal librarians showcasing the latest technology on presentation software, tablets, encryption, project management, and more. Equally invaluable (as always) is connecting with colleagues at both the Government Law Libraries (formerly State Court County) and Government Documents Special Interest Sections at the early-morning (7:30am and 7am!) business meetings.
My activities at the AALL included a presentation as a guest speaker at the FCIL-SIS meeting. This year, the section tried a new model to conduct its meeting, and in addition to discussing ongoing business, regional interest groups organized substantive presentations by guest speakers. At the invitation of the European Law Interest Group, I briefed the audience on recent legal developments in Ukraine. I focused on ongoing legal reform in Ukraine and reviewed recently proposed constitutional amendments. During the questions and answers, which followed my presentation, I was asked to explain which laws apply in occupied Crimea and Eastern Ukraine. Additionally, I described English-language resources on Ukraine available online.
On Tuesday, July 21, together with other academic and government librarians, I spoke on the panel entitled Law Library Interns: How to Make Them Work for You. Participants discussed how to make internships mutually beneficial for interns and host institutions and avoid miscommunication. Reviewing the Law Library’s experience in partnering with universities and other organizations, I provided examples of how to make internships and preparations for them less time consuming for an organization. I described specific projects initiated by the Law Library, which allow us to extract interns’ knowledge and use it to increase the efficiency of Law Library’s staff.
In regard to the learning experience at the conference, it was useful to attend panels where law librarians discussed how they digest data and statistical information in preparation of varied reference and research products, and what tools they use to make law reports more visually attractive.
SAN FRANCISCO — Americans have long stood out among residents of developed nations for how much they fret over, and are bankrupted by, health care costs. But well into the second year of expanded coverage under the Affordable Care Act, those worries have eased significantly in the nation’s most populous state.
A statewide survey has found that newly insured Californians no longer rank health care costs as their top financial concern. It has dropped below other essentials such as housing, utilities and gasoline.
“This was exactly the goal,” said Dr. Bob Kocher, a senior Obama White House official in 2009 and 2010 who helped draft the federal health care law. “Financial security was an enormous factor in our design.”Use Our Content This KHN story can be republished for free (details).
California has made swift gains in extending health coverage to its residents. It was one of just 15 states and the District of Columbia that opted for a state-based marketplace and expanded the publicly funded Medicaid program for low-income Americans. Those moves have paid off: About two-thirds of Californians who were uninsured in 2013 now have health insurance, according to the survey by the Kaiser Family Foundation, which was released Thursday. (Kaiser Health News is an editorially independent program of the Foundation.)
Since the state’s insurance marketplace, Covered California, made its balky debut in October 2013, some 1.4 million people have bought private health coverage, most with federal subsidies. But the biggest driver by far in reducing the number of uninsured has been the state’s hearty embrace of the law’s Medicaid expansion. Of Californians who reported being uninsured in 2013, according to the survey, 34 percent went on to enroll in Medicaid (known as Medi-Cal here). That has brought the number of residents covered by the program to 11.9 million.
The surge in enrollments, nearly three times higher than the state’s initial predictions, has strained an already overwhelmed health care delivery system.
Prompted partly by a deluge of complaints from Medi-Cal beneficiaries, a recent state audit found that the California Department of Health Care Services, the agency that administers the public insurance program, failed to guarantee that patients had adequate access to doctors, a requirement under state law. Physician directories were riddled with errors, the audit said, and phone representatives manning help-lines answered only a third to half of all calls.
Despite those failings, the Kaiser Family Foundation survey found the recently insured are largely satisfied with their coverage, including 83 percent of Medi-Cal enrollees and 63 percent of Californians who purchased private plans on the Covered California exchange. One positive, according to the survey respondents, was that they are having an easier time getting medical attention.
“I finally had the colonoscopy,” said David Bishop, a 60-year old construction worker, who enrolled in Medi-Cal after spending eight years without coverage. “The last time I had insurance, I had a wife and three kids, and you could make a house payment or truck payment for what insurance cost…[It] was so expensive we just did without.”
Among the recently insured, 86 percent said their health needs are being met, compared to 51 percent in 2013, and 76 percent reported having a consistent clinic or doctor’s office that cares for them, compared to 60 percent in 2013.
The survey also found a striking reduction in the percentage of recently insured Californians who struggled to pay medical bills: 23 percent said they faced difficulties, down from 45 percent in 2013.
“I’m paying one dollar a month,” said survey respondent Paul Marcus, a 62-year old physician assistant at a drug treatment center who signed up for a health plan through the state-run insurance exchange. The last time he went to buy health coverage, after losing his employer-based coverage in 2011, the $1,100 monthly premium was far more than he could afford.
Still, Marcus is cautious about using his medical insurance. “I think I’m on a bronze plan with a high deductible and high co-pay,” he said. “I’m still counting on trying to stay healthy.”
The survey found that the newly insured worry far less than the one third of the state population who remain uninsured. This group continues to rank health care costs as their number one financial challenge, according to the survey.
Forty-one percent of Californians who remain uninsured are not eligible for coverage because they are in the country illegally, according to the survey. Another 43 percent appear to fall into the category of hard-to-reach – they are eligible for coverage but had been uninsured for more than two years as of 2013. Twenty-nine percent of the remaining uninsured are Latinos who are eligible but have not signed up for coverage.
With its diverse population, the state struggled during the first year of sign ups to enroll its large Latino population. But a more concerted outreach effort, including through Spanish-language media, appears to be working. The Kaiser Family Foundation survey found previously uninsured whites and Latinos gained coverage at a similar rate: 79 percent of eligible whites became insured, as did 74 percent of Latinos.
Making health care more affordable was one of the law’s central promises. The law’s architects sought to shield low- to moderate-income households from punishing health care costs by limiting deductibles to $6,600 for an individual and $13,200 for a family plan in 2015 and providing federal subsidies. (Medicaid remains largely free to beneficiaries.) According to the Internal Revenue Service, 2.7 million American taxpayers claimed some $9 billion in subsidies; the average subsidy was $3,400.
And the growth in out-of-pocket spending is projected to have slowed from 3.2 percent in 2013 to 1.3 percent in 2014, according to the Office of the Actuary at the Centers for Medicare & Medicaid Services.
Although the law has eased the squeeze on wallets, a sizable number of Californians continue to report problems paying for and accessing health care. Three in 10 said they faced unreasonable waits for an appointment and 16 percent said a doctor’s office had refused to take them as new patients.
The survey, the third in a series designed to track how uninsured Californians fared as the health law rolled out, was conducted from Feb. 18, 2015 to May 13, 2015 and included 1,105 adults. The margin of sampling error is plus or minus 4 percentage points for results based on the full sample, 5 percentage points for recently insured Californians and 8 percentage points for uninsured Californians.
Data analysis and visualization software
We can’t be reminded too often that the fantasies portrayed in bodice-buster novels and porn flicks bear only a vague resemblance to what happens (and how we look) in real life.
So here, as part of our summer-listening revival of the best of our WBUR/Slate podcast, The Checkup, is a favorite, particularly juicy episode, titled “Sexual Reality Check.” It includes surprises about penis size, stories of great sex over 70 and new insights on how both men and women are lied to about their sexuality.The Checkup: a WBUR/Slate health podcast Subscribe on iTunes | The Checkup on Slate In case you missed other recent episodes: “Teenage Zombies” explored the curious minds of adolescents, with segments on sleep, porn and impulsive choices; “Power to the Patient” looked at ways we can all feel in more control of our health care; and “High Anxiety” included reports on hormones, parenting and fear of flying.
Better yet, don’t miss a single episode and just subscribe now.
After I gave birth to my kids, I was bombarded with advice from family, bestselling books and even strangers on topics ranging from how to lose the baby weight, when to have sex again and which infant toys boost IQ.
But according to a new, NIH-funded study, many sleep-deprived, hormone-addled new mothers may not be getting enough advice on critical issues from a most important source: doctors and other health care providers.
When it comes to breastfeeding, infant sleep position, immunization and pacifier use, many new moms report they get no advice at all from their children’s doctors — despite medical evidence on the benefits of certain practices, like breastfeeding and placing babies on their backs for sleep.
The new study — published in the journal Pediatrics and conducted by researchers at Boston Medical Center, Boston University and Yale University — found that about 20 percent of mothers said they didn’t receive advice from their baby’s doctors about breastfeeding or the current thinking on safe placement for sleeping newborns. And more than 50 percent of mothers told investigators that doctors did not offer guidance on where the babies should sleep.
(Of course the whole issue of where newborns should sleep is controversial. Official recommendations now say babies should “room share” with parents but not “bed share.”)
The study, part of a larger national effort called SAFE (Studies of Attitudes and Factors Effecting Infant Care Practices), surveyed more than 1,000 new mothers across the country, inquiring about infant care advice they received from different sources: doctors, nurses, family members and the media.
Dr. Staci Eisenberg, a pediatrician at Boston Medical Center and lead author of the new study, said in an interview that the number of moms who reported no advice from across the board is surprising.
“These findings say to me, ‘Hmm, this is a time to stop and think carefully about how we communicate, and are we communicating in a clear, specific enough way, and are we being heard, especially by new moms — new parents — who are often tired and likely overwhelmed?’ ” she said. “Amidst this sea of information, what are the messages that need to be highlighted and communicated clearly?”
Of course, the study relied on self-reported data from new mothers caring for 2- to 6-month-old babies, so caveats are in order. Still, the authors suggest several reasons that health professionals may hold back:
There are a variety of reasons that potential advisers may not give advice or may give advice inconsistent with recommendations. These reasons may include lack of knowledge of the recommendations, a perception of controversy surrounding the recommendations, or actual disagreement with the recommendations. It is possible that some health professionals may choose to avoid controversy or a lengthy conversation about potentially controversial guidelines during a busy, time-pressured practice.
Dr. Melissa Bartick, an assistant professor of medicine at Harvard Medical School and internist at Cambridge Health Alliance, who has written extensively on infant bed sharing, says the new study is “impressive.” But, she says, since the current recommendations on breastfeeding and sleep position “are not controversial at all (unlike sleep location and pacifiers)” the findings are a little troubling. In an email, Bartick, who was not involved in the study, writes:
“Doctors score incredibly low on breastfeeding and yet other studies show that their advice about breastfeeding is powerful. Hospital nurses do better, but still low. Sizeable portions of doctors and nurses give advice inconsistent with recommendations about breastfeeding.
The doctors and nurses scores on sleep position is even worse than for breastfeeding, with even lower appropriate advise and even higher inappropriate advice. There should not be any inappropriate advice, for either group, yet it’s 21% and 25% for these nurses and doctors respectively. That is truly disturbing.”
The survey did not ask mothers if they specifically asked for advice, Eisenberg said. Instead, moms were asked to respond “true” or “false” to numerous questions and then followup when appropriate. Here’s one example:
– My baby’s doctor (or health care provider) has given me advice about where my baby should
True False (skip to question #81)
— My baby’s doctor (or health care provider) thinks my baby should sleep:
1.Strongly disagree 2 3 4 5 6 7.Strongly agree
–alone in his/her own room
–in a parent’s (or other adult’s) room in his/her own bed
–in a parent’s (or other adult’s) bed for part of the night
–in a parent’s (or other adult’s) bed for the whole night
Eisenberg said pediatricians often spend less time than is ideal with patients — “we’re sometimes intersecting with people in such a sliver of their lives.” But these findings, she adds, could prompt a conversation about how the “public health community can think about interfacing with these other sources in order to promote child and parent health.”
She added one particular takeaway for parents: Get involved in your child’s health care. “I would always want parents to feel empowered to ask questions,” she said.
Here’s more from the NIH news release:
“Earlier studies have shown that new mothers listen to their physicians,” said Marian Willinger, Ph.D.., of the Pregnancy and Perinatology Branch at NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), which funded the study. “This survey shows that physicians have an opportunity to provide new mothers with much-needed advice on how to improve infant health and even save infant lives.”
African American women, Hispanic women and first time mothers were more likely to receive advice from their physicians than were white women and mothers of two or more children.
“As a physician, these findings made me stop and really think about how we communicate important information to new parents,” said…Eisenberg. “We may need to be clearer and more specific in telling new mothers about safe sleep recommendations. From a public health perspective, there is a real opportunity to engage families and the media to promote infant health.”
For the Study of Attitudes and Factors Effecting Infant Care Practices, the researchers enrolled new mothers at delivery from 32 hospitals around the country, with 1031 women eventually taking part in the study. The authors asked the women to complete questionnaires when the infant was between 2 and 6 months of age on advice they received from their infant’s doctor, birth hospital nurses, their family members, and the news media. In addition to finding out whether or not these sources had provided advice on infant care, the questionnaires sought to determine whether the advice was consistent with the recommendations of practitioner groups.
For example, the American Academy of Pediatrics (AAP) recommends that caregivers always place a baby on his or her back for sleep at night and for naps. The women in the study were asked whether they agreed or disagreed with a series of statements on sleep placement: “The nurses at the hospital where my baby was born think that I should place my baby to sleep on the [back, side or stomach.]” If the women agreed with the statement that the baby should be placed to sleep on his or her back, the researchers classified the response as consistent with the AAP recommendation. Agreement with statements on the other placement positions was considered inconsistent with the recommendation.
When it was given, advice from physicians tended to be consistent with recommendations. However, 10 to 15 percent of the advice given on breastfeeding and pacifier use was not consistent with recommendations, and slightly more than 25 percent was not consistent with recommendations for sleep position or location. Interestingly, of the women who reported physician advice on sleep position that was inconsistent with recommendations, 85 percent reported being advised to place the infant on his or her back and at least one other position–usually the side (which confers increased risk for SIDS relative to back position). In comparison, of the more than 32 percent of mothers reporting family advice regarding infant sleep position that was inconsistent with recommendations, 51 percent had been told to place infants to sleep on their stomach (stomach sleeping has been associated with the greatest increased risk for SIDS).