Oh, Shut-Up WebMD

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As a Registered Nurse, I love WebMD. It’s a great resource for people on both sides of healthcare, and it doesn’t usually let me down. I even subscribe to the e-newsletter.

The slideshow I received in my inbox, with the attention-grabbing title 10 Ways to Wreck Your Liver: Is Your Liver in Danger? as a part of the special Your Most Pressing Health Concerns, could not have been more perfectly timed. It was a day filled with candy, food and a booze-soaked Raclette at my house, while my in-laws were visiting for the holidays. When I saw the subject line I thought maybe it was a sign and I leaned in closer.

As it turns out, I was disappointed after following and viewing the link in the e-mail (if clicking and waiting for a slideshow to load isn’t less than impressive already) so I dropped WebMD a little shit-o-gram to express my views.

I was a little annoyed to see antidepressants on the list of “Ways to Wreck Your Liver” in the newsletter just sent out.

The list seemed to include mostly elective lifestyle choices like consuming sugar and MSG – things a patient can safely reduce on their own. Antidepressants on the other hand are oftentimes life-saving prescriptions and should not be stopped abruptly unless a doctor is supervising. They are not an herbal supplement a patient can just ‘quit’.

True, they are known to rarely cause hepatotoxicity, particularly with the older MAOIs and tricyclics that are less prescribed. In fact many medications for serious chronic conditions can cause liver damage, but I didn’t see them on this list. And I feel that listing antidepressants here may cause unnecessary alarm in a group of patients already known to struggle with compliance.

I suspect antidepressants’ special mention is a residue left over from the attitude that those taking these drugs are just participating in cosmetic psychopharm and are not really ill.

Can we stop the out-of-proportion reporting of the adverse effects of antidepressants where it is not warranted? Information is power, but finger-wagging just creates more shame. Thank-you.

Acetaminophen toxicity is the leading cause of acute liver failure in the Western world. That’s Tylenol.

Overdose on Tylenol may be intentional or accidental, especially if you are an older adult, or your liver is already compromised. This is something all nurses and doctors know because it is one of the more common medication-related injuries seen in hospitals. It continues to be a major problem in ERs and, in the case of accidental overdose, people are not warned nearly enough of the dangers of taking more than what is recommended.

Liver failure from a daily antidepressant medication? I would have to argue is less common. If a publication was to cover the adverse effects of one drug, why would the subject of focus be a prescription medication for a serious, chronic condition over and above a non-prescription pain reliever that the public has universal access to from infancy through adulthood in their medicine cabinet? Editorial bias? Bad journalistic priorities?

My tone here mirrors my reactionary thoughts I had to the well-covered findings of a recent study which showed a weak but statistically significant link between SSRIs taken in pregnancy and autism.

And this article sums up in a more accurate, cool-headed manner why we all don’t need to start freaking out and tut-tutting at other moms.

You may have heard this study reported in early December on your local news or radio station while you were driving. It probably was squeezed in at the end of the program and went something like this: “And a recent study has shown a significant link between SSRIs taken in pregnancy and childhood autism…. And that’s all we have for today, folks….” This type of quick-digest reporting is not harmless. It creates misunderstanding, alarm, and guilt.

I guess what I’m trying to say here is, if you smell bullshit, it’s best to call it out. No one is arguing where the smell is coming from, but its placement in the middle of the sidewalk may not be appropriate.

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Moody Bitches: Book Review

I have officially become a Julie Holland fangirl.

A few days ago I walked in the bookstore alone, with the pleasure of sinking into a hot bath. Dr. Holland’s book title jumped off the shelf. I flipped through its pages and I was won over by her intimate, down-to-earth writing style and wisdom, and of course the subject matter. But I had to know: what was Dr. Julie’s verdict on medication to treat mood disorders? Appropriate in the right circumstances or just another ‘cure’ worse than the disease?

She seemed very grounded in today’s reality for women. The book appeared well-researched, referencing studies that had been popular when they were first reported, and also ones I had not heard of. Her voice was compassionate; not at all patronising. Working in a psychiatric ER for 20 years, with a private practice thereafter, should give you some solid street cred. But I needed to find a passage first that proved what I hoped:

“I’m not suggesting that all use of psychiatric medicines is counterproductive. People who don’t really need these meds are taking them, while people who are genuinely psychiatrically ill remain undiagnosed[…]. Clearly there are times when we need to pull out the big guns.”

Perfect. So I bought the book. Not cheap either – $35 Can. for hardcover!

The look of this book might scare some people off, who have experienced the nightmare of a severe mood disorder – we don’t need any more guilt heaped on our full plate. But Dr. Julie makes her message clear – our proper treatment of mental illness is so important, but we cannot let that slip into a war on emotionality. Our moods in all their highs and lows should be honoured as a rich human experience and respected for their wisdom. Being a woman sometimes means being a tiger or a growly mama bear. As Dr. Julie put it best, “Being fixed and rigid does not lend itself to survival. In nature, you adapt or you die.” Sometimes that means showing your teeth and voicing unhappiness.

Recovering from a mood disorder means making peace with the trauma of having your mind betray you deeply. In recovery you are hypervigilant for the return of that black beast – when we are tearful or sad, obsessive or anxious – what is healthy and what is worrisome? This book is a good start for someone looking to repair that relationship with their emotions.

It is smart, feminist, and scary – like Girl Interrupted read  Lean In. It discusses the dangers of direct-to-consumer marketing by pharmaceutical companies, and the advent in the ’90s of disorders that are not really disorders. Cosmetic psychopharmacology is another bull in the arena that women have to fight in the workplace. How do we stay authentic and taken seriously? Our expressed emotions are a call to action – spurring growth and change. How does our sadness and anger and anxiety remain dynamic, when everyone around us is taking Xanax and just floating by on the status quo? Our emotions are the root of our empathy, our ethics, our humanity.

Moody Bitches is practical, too. The appendix is great for anyone who feels they aren’t getting enough straight talk on medication options from their doctor. Cover to cover is packed full of information and helpful instruction for women with our unique biology in mind. It is a reliable resource that doesn’t just throw the experience of being female all in a messy pile and call it ‘raging hormones’. Dr. Julie tidies up, and makes our hormones and their role in our lives and bodies more clearly understood. Women who suffer from misunderstood conditions like Premenstrual Dysphoric Disorder or Postpartum Mood Disorder will feel refreshingly validated. Getting sunshine and exercise or not just presented as ‘complimentary’ but necessary for our bodies to feel well. And so importantly – she hits home that medications like seratonergic drugs and oral contraception can potentially knock your libido out – something doctors usually skirt around in their office.

I highly recommend this book to everyone – women and men, moody bitches and even stevens. It’s a resource for the average girl, and not just that, it’s a great reference for healthcare providers, too. It contributes to a tremendously relevant conversation that we should be having. One that I hope I am helping to bring more to the table, too.

 

 

The Cost of Not Helping Moms

Photo Chris Ryan, Getty Images

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Postpartum Depression is thought to affect at least 10-15% of mothers in Canada, according to a major national study from 2011.

Please take a moment to consider how many women that is. That is nearly one out of every 6 mothers.

But those are only the occurrences we know about. Because even a gold standard study of postpartum mood disorders supported by the Public Health Agency of Canada has some major flaws.

For example, lets look at how information was gathered for this study:

In the provinces, women were cold-called for computer-assisted telephone interveiws that lasted on average 45 minutes. In the territories, a paper survey was distributed in areas where a phone was not available in the household.

The Edinburgh Postnatal Depression Scale was used. This tool was developed in 1987 in Scotland. It is valued for its efficiency because it is only 10 questions long. Furthermore, it is concerned only with experiences of the mother in the previous seven days, so if you recovered from a perinatal mood disorder a month ago, no one is asking.

Stats Canada selected a group of 8, 542 women ages 15 and over who had had live singleton births.

IT EXCLUDED:

  • Mothers of twins and multiples
  • Mothers of stillborn babies
  • Mothers younger than 15

Who is more at risk for a postpartum mood disorder than a mother of multiples, a stillborn baby, or a mother under the age of 15? Why are these women excluded from the data? Why are they not being represented?

This study was a cross-section taking place over a matter of a few months, it was not longitudinal. This is problematic. Women in Canada have on average 2 living children. So obviously, a study that only collects data from one pregnancy at a time, is forgetting that the same woman will likely have more children, or has already. We want to know how many women will have been affected by postpartum mood disorder in their life, NOT just who had it the week of the phone-survey.

Very concerning is that out of the 8,542 women, only 6,421 mothers responded to the survey.

HERE ARE SOME REASONS WHY A MOTHER IS LESS LIKELY TO RESPOND TO A GOVERNMENT-ISSUED SURVEY:

  • You have postpartum depression. And feeding and diapering your child is your only priority right now.
  • You’re terribly ashamed and don’t want to tell anybody what you’re going through, let alone admit it to yourself. A symptom of postpartum mood disorder is thinking that you are the worst mother in the world. A woman can be an excellent mom and still think that, if she is suffering from this illness. A common fear is that if they disclose their illness, they will have their kids taken away.
  • Postpartum mood disorder is enormously stigmatized. What if someone in your family reads your survey responses? Or hears your responses while you’re talking on the phone? Imagine if there was a similar phone survey to collect answers from victims of domestic violence or sexual assault? Would that not be hugely inappropriate? It’s absurd.
  • “Is this person on the phone for real? I can’t see their face; they’re asking such personal questions, and they want me to talk about my mental health? While my in-laws are here??”
  • You have poor literacy skills (which also can increase your PPMD risk).
  • You come from a first nations/rural/remote community, where there is a history of strained relations with the government.
  • The person on the phone is English-as-a-second-language and you struggle with non-English accents.
  • You have a child hanging off one breast or you’re trying to heat a bottle, and the dog is barking at the door.
  • You saw the unfamiliar number on the phone and yelled, “Kids, don’t answer it!” because you definitely don’t have 45 minutes to answer questions like how much money your husband makes.
  • You have to pick up your older kids from hockey, there are bills to pay, the fridge is empty, it’s 8pm, and the stove is cold

I Think You Get the Picture.

“…Why, in the hospital, could I [receive] the services of a lactation consultant but not of a mental health professional to discuss PPD? Why did my OB/GYN stop by my room every day to check my Cesarean stitches but not my state of mind? During my pregnancy, my husband and I had to take six birthing and parenting classes in which we practiced putting on diapers and installing car seats but did not discuss maternal care options.

Angela Pandolfo Roy, My Voice Didn’t Soothe Him, My Touch Didn’t Comfort, 2007

The true statistic is obviously a lot higher than we can imagine. And that number can include women like your sister, your best friend, your wife, your daughter, or it could have been your own mom at one point.

And the bottom line is – mothers are not getting help.

The consequences of UNTREATED perinatal mood disorders on children are serious and cannot be overlooked , .

  • Impaired infant bonding
  • Difficulty establishing breastfeeding, which is also associated with depression
  • decreased performance in school-age children
  • Delay of developmental milestones
  • Decreased weight gain and thriving in infants
  • Increased risk of SIDS
  • Behaviour problems
  • Difficulty in making secure relationships throughout life
  • A greatly increased chance of children having a mental health disorder like depression, anxiety, ADHD, or autism
  • Increased chance that children participate in crime or drugs
  • Stressful marriages and family environment

In 2012, as reported by the Globe and Mail,

“…more than 49,000 Canadian mothers experienced depression within the first 12 months after giving birth, putting at least 80,000 children at risk for poor development.”

Furthermore the downstream effect of UNTREATED perinatal mood disorders on our healthcare system is just enormous:

  • A national Canadian figure is not available, but lack of maternal mental health care costs the UK £8 billion a year, the US $1 billion and Australia $433 million.
  • When moms don’t get help right away, their first point of entry with the health care system is usually with acute inpatient services
  • Increased pressure on an outpatient care stream that cannot adapt to the individual needs of moms vs. other members of the public
  • Unnecessary trips to the ER, for mothers and children in crisis, or unknowingly suffering symptoms of anxiety or depression (ever heard, “oh, she’s just a nervous/new mom”?)
  • Increased doctor visits and repeated contact with the health care system, while a resolution is not found
  • Mental illness of any kind is associated with chronic diseases such as heart disease, stroke, dementia, obesity, diabetes, and hypertension
  • Increased risk of self-medication with drugs and alcohol, and during successive pregnancies
  • Increased sick days and sick leave time from work
  • Less likely to follow up with adequate prenatal care, which leads to problems such as early termination of pregnancy or complications at delivery time
  • Increased usage of social work or police in a crisis situation
  • In the case of very severe mental illness, such as postpartum psychosis, there is a risk of infanticide, although rare
  • suicide

Referring to Canada’s embarrassing lack of information on maternal suicide, also from the Globe and Mail:

“In contrast to Canada, Britain has rigorously analyzed maternal deaths for more than 50 years to sift out contributing factors. The findings are astonishing. When maternal deaths between 2000 and 2002 were examined, for example, psychiatric illness accounted for the majority of those deaths. Put bluntly, more mothers died by committing suicide than by succumbing to any other medical complication, such as hemorrhage or heart disease.”

Mothers are the bedrock that shape our families and our communities, both local and beyond. So it’s no wonder that when moms are sick, it affects everybody.

Postpartum mood disorders are not somebody else’s problem. They are not something that expecting women or moms alone should watch out for. We are greatly underestimating both incidence and impact of these illnesses.

 

We’ve heard of things like postpartum depression before. So why should we do anything differently? In the words of our new Prime Minister in response to why he appointed a 50% female cabinet,

“Because it’s 2015.”

And we are failing moms. We have been, and we still are.

Why is this? Despite the fact that so many women are ill, we have a really hard time talking about postpartum mood disorder.

Mothers are supposed to be happy and glowing after the birth of their child, right? They just have to be. Any challenging of that view creates enormous cognitive dissonance, and we quickly sweep it under the rug.

And by sweep it under the rug, I mean we give out a pamphlet with ten questions, spend more time going over proper fit of the car seat, wave them off, and hope for the best.

We need to do more in our communities for moms, and the time to start is now.

We need to improve access to information on perinatal mood disorders for both healthcare providers and the public.

We need to improve screening, such as at regular paediatric doctor visits throughout the first year and beyond.

We need to improve our screening tools, so that we don’t miss any of the warning signs and symptoms (there are more than ten).

We need to improve follow up.

We need to improve the doorways to the healthcare system so that moms can be connected with people who can help.

We need improved access and response time so that moms don’t have to wait months for a therapist who specializes in perinatal mood disorders.

We need more support groups of other moms going through the same thing.

We need more teams of health care warriors, ready to stand up for moms and fight perinatal illness.

If you are in health care, your presence here, reading this, is a great start. I hope you share this call for action with other health care providers – nurses, doctors, paramedics, social workers, counsellors, anyone who will listen.

If you’re not in health care, then you are still one of two: someone who knows a mom, or someone who is a mom. And you have two choices: to pretend this problem is not as big as it is, or to raise your voice.

Because when moms get better, everybody gets better.

– Jessica C., RN, BN

 

 

Antidepressants Are Options

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There is a constellation of facts and emotions swirling around antidepressants, always. And the big feelings around antidepressants are of suspicion, anger, judgement, pressure, guilt, and shame. And a lot of times, facts get misused or distorted, or completely invented.

I am pro-pharmaceutical.

I am also pro-meditation/mindfulness, pro-cognitive behaviour therapy, pro-eating right and exercising, pro-sunshine, and pro-vitamin B6. I am pro-GETTING BETTER.

A mood disorder (like anxiety or depression or bipolar) is a physical illness. Why? It takes place in a PHYSICAL body (where else?) and it is hurtful; it’s not conducive to thriving or living your life. It is body stress. And just like other kinds of stress or inflammation, it is accompanied by biochemical markers like increased cortisol and cytokines in your bloodstream [source].

Anxiety and depression disorders are excruciating. They are agonizing to go through and create alienation and isolation around a person. They create chaos in families. NO ONE chooses to be anxious or depressed any more than they want to hold their hand against a hot stove burner. In a culture of shame and judgement, most symptoms are covered up, hidden, and disguised as much as possible. What you see, if you see any signs at all, is usually just the tip of the iceberg.

The decision to treat your mood disorder is a painful one and it requires a lot of courage. More difficult, is when people battling their anxiety and depression get caught in a larger battle – Treat With Drugs vs. Without Drugs.

I roll my eyes when mental illness is called an ‘invisible illness’ – it is no more invisible than any other kind of injury on the inside of the body, as opposed to the outside. By that definition – a physical illness somewhere that isn’t on the skin’s surface – a knee injury is an ‘invisible’ illness. Heck, most soft tissue injuries are invisible. A GI disease like a hernia or ulcer that isn’t seen by the naked eye is an invisible illness. Just like with other physical illnesses that can’t be seen on the outside of the body, mental illness is initially diagnosed based on the patient’s reported symptoms, such as pain and impaired functioning. But are conditions like carpal tunnel or a pulled muscle as de-legitimized and stigmatized to the level that mental illnesses are?

Illnesses that happen in our most vulnerable organ – the brain – are the hardest to examine by doctors. So in the absence of information, comes a lot of opinion and judgement. Sadly, most of it is negative because the signs and symptoms of mental illness can resemble extremes of normal emotions in healthier people. And therein lies the key to understanding the stigma. Because we can’t open up the brain’s minute circuitry to look inside as easily as we can view somebody’s GI tract with a scope, people create assumptions about WHY people with mental illness are suffering. They make the mistake in thinking that victims of mental illness are not doing enough to cope on their own, when in reality their brain is creating a situation that is overriding their capacity to cope.

The brain is not inherently mysterious; we just don’t understand it well, and perhaps we won’t for a long long time. When something is beyond understanding, it is human nature to fall back on familiar points of reference – such as ourselves. In ancient times we thought lightning was caused by a human-like god throwing spears of fire. So when someone can’t come to grips with a loved one’s depression, their solution to the problem is like pouring a cup of water on an inferno. What works for them, won’t work for someone with depression.

This all seems pretty obvious, but it brings me to my next point.

If you have never needed a psychiatric medication, you cannot possibly begin to condemn someone for taking one.

Mental health medication gets a lot of bad press. It’s not surprising why. Psychiatry and medicine has a sad history of over-prescribing, chemical abuse and oversedation, calling normal human experiences ‘disorders’ that require pills when they don’t, making considerable profit by exploiting desperate people, creating addiction and causing permanent damage, and the list goes on.

BUT that doesn’t mean under the guidance of an ethical health care provider you cannot find a SAFE option for you and take it responsibly. It doesn’t mean that you should be judged or shamed for needing medication, or that medication is a bad thing when prescribed and taken responsibly. It doesn’t mean that you are copping out. Or taking a shortcut. Or not trying hard enough. Or have a weak or addictive personality. It doesn’t mean you are a pill-popper. Or a junkie. Or a bad mom or a bad husband.

I am SICK up to HERE with the subtle and not-so-subtle message towards people who take mental health medication. If you can take some vitamin B12 and a sniff of lavender essential oil before bed to manage your depression and anxiety, that’s awesome. But don’t go writing an unsourced airy fairy blog post about how the pharmaceutical industry is just trying to kill everybody and you should feel nothing but shame and guilt for relying on some sketchy chemical from a lab, that is little better than a placebo. Just ask anyone lucky to find an SSRI that worked for them – the effect is the complete opposite of placebo.

And for every industry worker for Big Pharma I swear is some alternative asshole trying to make money by selling you holistic oils and crystals, but I digress.

We need to remember that mental health should be treated the same way all other issues in the body are – with titration, and appropriateness. If someone comes to the ER with a hangnail you don’t just throw some hydromorphone on it. Or just as bad – if someone comes with their foot cut off you don’t ask if they tried icing it first.

So yes some things like meditation and sunshine and essential oils and vitamins and good nutrition and a sweaty workout and cognitive behaviour therapy  and a big old handful of cashews daily will manage some mood disorders. But not others. That is why antidepressant options remain just that, options. And non-invasive non-medical things should be continued as supportive therapy.

So are you failing if you need it? No way. You are trying your best. Haters can hate. You just keep on keepin’ on your healthy way. With your head up. And a middle finger in the air. If you need it.

– Jessica C., RN, BN