Major depressive disorder (hereafter referred to as "depression") is a prevalent and disabling illness. According to the National Institute of Mental Health:
Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44...[and]...affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year.
There's been some terrific writing on depression around ScienceBlogs this year. I've written a few pieces touching on mental illness in the past, but never anything explicitly about depression. Given the frequency and impact of this disease, it's time to have a frank discussion. This was spurred in part by an acquaintance who reads my blog and has struggled with depression herself. She happens to be a pretty good writer and was willing to share some of her experiences with us.
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A long while back, at the original wordpress incarnation of this blog, I wrote a piece on the reasons that chiropractic is unscientific nonsense. Because it was popular, I moved it over here. Well, a chiropractor has come to bravely defend his field and left us a comment.
A study in the May 2007 issue of the Journal of Manipulative and Physiological Therapeutics reports health plans that use Chiropractors as Primary Care Providers (PCPs) reduce their health care utilization costs significantly.
The study covers the seven-year period from 1999 to 2005. Researchers compared costs and utilization data from an Independent Physicians Association (IPA) that uses Chiropractors as PCPs and a traditional HMO that doesn't.
The Chiropractic PCPs had 59 percent fewer hospitalizations, 62 percent fewer outpatient surgical cases and 85 percent lower drug costs compared with the HMO plans.
The patients in the Chiropractic PCP group also reported higher satisfaction with their care than the HMO group. Over the seven-year period, Chiropractic patients consistently demonstrated a high degree of satisfaction with their care that ranged from 89 percent to 100 percent.
Study co-author James Winterstein, D.C. says that patients using Chiropractic PCP health care groups "experienced fewer hospitalizations, underwent fewer surgeries and used considerably fewer pharmaceuticals than HMO patients who received traditional medical care."
Hmmm...interesting assertions. Let's examine these assertions and the "article" they come from.
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(NB: as is usual with my more "science-y" posts, oversimplification is the rule. --PalMD)
It's been a very long while since I've updated my series on cancer. I keep meaning to, but you know how things go. Lately, though, I've been curious about radiation oncology, the use of ionizing radiation to treat cancers. What set me off was a recent Times article about some pretty crappy practices. Radiation oncology requires a very thorough education in physics and medicine and the field attracts some of the best minds, but no field is immune to unethical behavior (which in this case I feel is more important than the incompetence itself).
Anyway, radiation---it scares the crap out of people. We call magnetic resonance imaging "MRI" instead of the original "NMR" (nuclear magnetic resonance) mostly because the idea of being in a machine with the word "nuclear" on it freaks people out. Of course, radiation is a normal part of living. We are exposed to high energy electro-magnetic radiation daily, both from the Earth and from space. If fact, ionizing radiation from the sun is the primary cause of skin cancer.
Very shortly after ionizing radiation was discovered in the late 19th century, it was applied to the treatment of cancerous tumors, albeit in a very crude way. As knowledge of physics and medicine grew, so did the sophistication of treatments. Early on, of course, it wasn't understood exactly how radiation damaged living tissue. If you aim x-rays at healthy skin for long enough the skin starts to turn red in a way similar to a sun burn. If you want to get that radiation to a tumor somewhere under the skin, then simply aiming an x-ray at the skin above it is going to kill skin long before it kills tumor. Thankfully, people are rather clever. In the early 20th century, doctors tried inserting radium directly into tumors, and tried fractionating treatments of external beam radiation so that each individual dose was not too toxic to the overlying structures. These techniques allowed killing more tumor cells than normal cells.
But let's back up a little here and examine some of the basics.
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Medical science rarely undergoes revolutionary changes. Progress tends to be slow and steady, with new ideas undergoing extensive investigation before being implemented. This pace can be frustrating and every once in a while, someone comes along who thinks they have discovered The Secret to It All. Despite the apparent insanity of such grandiosity (or perhaps because if it), you can always rely on the Huffington Post to give it a platform. (Interestingly, most of these Ideas can't be simultaneously correct, but that doesn't seem to bother HuffPo).
The latest Revolutionary Thinker is Dr Frank Lipman who writes about what he calls "the myth of diagnosis". Let me remind you what "diagnosis" is (paraphrasing liberally from an earlier post).
We have a couple of ways of going about defining diseases. One is pathophysiological where we can clearly see a disruption of normal function or anatomy. Another is genetic; if we can trace pathophysiologic changes to a specific genetic change, Bingo! Of course, genes are rather complicated, and the relationship between genotype and phenotype can sometimes be frustratingly variable. But no one said science would be easy.
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Everyone who uses the internet leaves some sort of footprint, even if it's just a string of visited addresses. This presence is magnified if you've ever been in the news, been listed on a website (e.g., as faculty), or if you write a blog. Social networking sites such as facebook and Twitter add a whole new dimension of online presence. Everyone should be concerned about what their online presence says about them (if your public Amazon wish list is full of sex toys, for example...) but physicians should have special concerns which fall into some broad categories. First, we'll briefly discuss types of online presence.
Your online life
Who hasn't vanity googled? Googling yourself can be interesting and instructive. If you have publications, are listed on a website as a contributor to a charity, or anything else searchable, someone can find this out. It's probably better to find out for yourself before you hear about it. As mentioned above, public profiles and wish lists at places like facebook, Amazon, and eBay are often included in search results, as are basic components of facebook profiles. Your online presence is dramatically larger if you are involved in web-related activities such as blogging. Even if you blog anonymously, it's likely that eventually, a search will link your real name to your blog and everything you've written there even if you've deleted it. Different types of online presence present different challenges.
- facebook: parts of your profile are visible publicly, and depending on your privacy settings, a great deal of information about you is visible to "friends" and many other members. Critically, this includes your status updates. If you write, "I LOVE CHEEZE!!!" people may think you quirky, but there's little harm. If you write, "I LOVE BONG HITZ!!11!!!" this is information that is going to be available to many others, and there is a good chance that it may become available to colleagues and patients. This would generally be a bad thing.
- Twitter: twitter is like having only the status updates from facebook, but relationships with other tweeters tends to be looser, and many people have hundreds of followers whom they do not know.
- MySpace: if you are on MySpace it's probably past your bedtime (or you're on a special "list").
- Blogs: blogs contain an enormous amount of information about how you think and what you believe, and this information is, for all intents and purposes, permanent.
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I've been a bit remiss in my coverage of the Simon Singh case, reviewed in detail by Phil Plait, among others. As many of my readers already know, respected science writer Simon Singh is being sued for libel in England by the British Chiroquacktic Association (BCA) because he described some of their treatments as "bogus". Despite the fact that he underplayed his hand, he is still getting his legal ass whooped over in the motherland, thanks to their idiotic libel laws.
Be that as it may, the BCA wasn't complaining about Singh being wrong, but about him being mean. You see, "bogus" seemed to imply not just that they were a bunch a stupid twits, but that they were dishonest stupid twits, and that's just too naughty.
But as stupid twits often will, they are no longer able to hold back. They are now insisting on showing off just how stupid, twittish, and wrong they really are. In a response to L'affaire Singh, the BCA has posted a broadsheet defending their particular type of prescientific quackery.
(As an aside, I would like to remind my readers about my thoughts on "quackery from ignorance". Just because a quack believes in what they do does not exculpate them from the wrong they are doing. They have taken on a special responsibility, a grave responsibility to people in pain, and to honor this, they must be extra vigilant, sort of like real doctors. Ignorance is not a viable excuse for bad medicine.)
Anyway, since the arrogance of ignorance has trumped common sense, let's take a look at what the BCA is offering us.
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When I look at my daughter, what do I see? There is so much in every glance. Usually, she's moving too fast to pin down, running at me yelling, "Daddy!!!" I don't know how anyone even looks at their kids without tearing up, even a little. There is of course a narcissistic joy in having someone around who (for now) loves you unconditionally. But there's more.
When my daughter was a baby, she had the biggest eyes, like out of a Japanese cartoon. They were what everyone noticed. One day when I was pulling into the hospital I looked into the rear view mirror and I saw her eyes looking back at me. My eyes, with their heavy brow and cynical glint were the same shape as the ones that blinked at me in the morning when I changed her diapers. But strangely, they were also her mom's, so big and round, taking in everything, missing nothing. And yet when she began to speak, her voice was her own, and still very much is.
I've always carried my daughter on my shoulders, and she's always cooperated by being quite little. Yesterday on our family walk she asked for "uppy" and she wasn't quite so easy to hoist up. I really gonna hate the day she can't ride on my shoulders.
I know that life has a trajectory, that her growing up means my learning to live with that. I really know, so I try to suck up every second. I try to sneak home from work early, or put off her bedtime, or whatever else I can do to get a few more seconds of cuddles.
I can't say it's not nice this evening. I'm sitting in my back yard with a cold beer, looking at the garden we planted together, the three of us, up at a blue sky, with a gently breeze making the maple leaves shimmer. But my daughter is out tonight, giving my folks a well-deserved portion of her love.
Damn it I miss her.
I'd like to direct your attention toward an excellent discussion of today's news about the cold "remedy" Zicam. Dr. Novella and the commenters have hit on all the major points; I can't improve on it.
I would, however, like to give you a personal look at anosmia, or the absence of a sense of smell. It is not at all OK. I have rather nasty seasonal allergies and I also get a lot of upper respiratory tract infections (presumably due to my constant exposure). Several years ago, I came home from the hospital with a nasty cold, had some soup, and went to bed. The next morning I got up and made a pot of coffee. I checked the pot a couple of times to see if it was working as I didn't smell it brewing. I poured a cup; it was nice an hot. I took one sip, and spit it out. It tasted terrible. I couldn't smell any of the subtle aromas of the coffee. All I could appreciate was the bitterness on my tongue. Breakfast was similarly horrid. I could appreciate some sweetness and sourness in the yogurt, but that was it.
This was my first experience with anosmia, and everything was different. I couldn't smell the gas from the stove, the exhaust of the traffic, or the upholstery in my car. The antiseptic smell of the hospital was gone, but so was the smell of urine. It turns out, though, that many "smells" have a strong "taste" component. Certain unpleasant smells, such as the diarrhea associated with C. diff colitis, were still apparent to me, but instead of sensing it in my nose, I sensed it in my mouth. This shift of sensory focus was not a welcome experience.
It took about a month for my sense of smell to fully recover. I've become fully or partly anosmic almost yearly since, and it's one of the things about winter that I dread. I certainly don't need any help losing that particular sense.