Scary tactics

The Kandiyohi County Drug-Free Communities Coalition is in the midst of surveying students about their perceptions and priorities, and a rather interesting preliminary finding has emerged: Many of the kids believe scare tactics are an important – perhaps even necessary – strategy for discouraging young people from tobacco and alcohol use.

But are tricks really better than treats? There’s in fact mixed evidence on whether scare tactics truly are successful at getting people to change their health-related behavior.

Look no further than the FDA’s new cigarette label warnings, which go into effect in September 2012. Unlike the current warnings, which are text only, the new ones are larger and more graphic – one of them features a photo of a corpse.

Will they be effective? There’s some international research suggesting that blunt, scary tobacco warnings can result in an increase in the number of smokers who want to quit. For other people, though, it’s likely to be a turn-off.

Repeated exposure to frightmeister messages often dulls the impact, Jonathan Whiteson, director of the Cardiac and Pulmonary Wellness and Rehabilitation Program at New York University’s Langone Medical Center told USA Today earlier this year. “We become immune to the negative warnings over time. The more graphic the image, the more likely the message will become marginalized.”

Another drawback to fear-mongering is that the effects often aren’t very long-lasting. After a health scare, for instance, people tend to have trouble sustaining their motivation to live better. When Truth on Call conducted a text message poll for on this issue, 47 percent of the 100 family physicians who were surveyed said their patients’ good intentions lasted for only a few weeks. A depressing 2 percent of the poll respondents said patients went back to their old ways within one day.

There seems to be some recognition in the health care world that browbeating patients with scare tactics has a way of backfiring. When the Clinical Diabetes journal published an overview in 2007 of best practices for encouraging patient adherence with diabetes management, it included a list of what not to do: “do not establish rapport; tell patients what to do; take control away from patients; misjudge patients’ sense of the importance of behavior change and their confidence in achieving change; overestimate their readiness to change; argue with patients; blame them for not taking better care of themselves; and use scare tactics.”

Unfortunately the dividing line isn’t always clear between what constitutes enough information and what’s too much. What’s the difference between scare tactics vs. fully informed consent? Are scare tactics more acceptable in public health campaigns than in the doctor-patient encounter? Do they work better among adolescents than among adults?

Ultimately, some of this seems to boil down to individual preferences and how the message is delivered.

When researchers interviewed obese African American patients for a study published two years ago in the Journal of General Internal Medicine, they uncovered some interesting nuances about how these patients perceived the use of weight-loss scare tactics. “I like to be scared. Scare me with all the bad things that can happen if I don’t lose weight,” one of the patients told the researchers. But others didn’t like it and even found it intimidating. “I look at it as a threat. The only thing the doctor should do is encourage,” was the response from one patient.

The upshot? Scare tactics seem to work sometimes, but they don’t work all the time and with many patients they’re counterproductive. Clinicians would do well to tailor their message, the researchers wrote. “Providers must be cautious when employing scare tactics as a means to promote lifestyle change to achieve weight reduction as not all patients respond well to this technique.”

West Central Tribune file photo

The satisfaction gap

For all the talk about patient satisfaction and patient-centered care, it seems many clinicians don’t really know what their patients want or expect – and often don’t even ask them.

The British Medical Journal: Quality and Safety recently published the results of a rather intriguing survey that reveals a pervasive blind spot when it comes to understanding and managing patient expectations. Of the 1,004 survey responses from clinicians at four academic hospitals in Denmark, Israel, the U.K. and the United States, nearly 90 percent said it was important to ask patients about their expectations but only 16 percent reported actually doing so. Moreover, four out of five felt they were inadequately trained to manage patient expectations.

I’m not sure how well these findings reflect general attitudes by clinicians toward patient satisfaction; this was a relatively small study, after all. It highlights a persistent disconnect, however, between patients and the health care system – namely, that those who work within the system often don’t really know what patients want and don’t take the time to ask.

Which raises the larger question: Is this because they simply don’t know how, or is it because they don’t buy into the concept of patient satisfaction to begin with?

There’s considerable debate within health care about the extent to which patient satisfaction should matter. Should it determine how much hospitals get paid? Should it determine how much physicians are paid?

For an example, look no further than the testy discussion taking place at Kevin, MD, in response to a guest entry by Steve Wilkins, a consumer health behavior researcher and former hospital executive, about patient-centered care.

Much of health care remains strongly provider-driven, Wilkins points out. Allowing patients more involvement in their care doesn’t mean letting them call all the shots, he writes; “it simply invites them into the party and gives them a place at the table. As providers, we don’t do a good job of listening to patients. We do an even worse job when it comes to acting on what patients tell us they want.”

“What’s missing from medicine is NOT more time spent eliciting patient opinions about their care,” retorted a psychiatrist. “A patient is no more a partner in their care than I am a ‘partner’ of my auto mechanic when he adjusts my timing belt.”

Someone else scoffed, “This is ridiculous and a reflection of our increasingly entitled and whiney society.”

Can you say “doesn’t get it”?

Fortunately, there seems to be a growing number of institutions and clinicians who do get it, or are at least trying. It’s interesting to note that in the British Medical Journal survey, the vast majority of the doctors and nurses who were surveyed believed it was important to know what their patients want. Where they most often fell short was in putting their beliefs into action, suggesting that part of the gap in meeting patient expectations may lie in a lack of skills or confidence to address this.

In fact, the researchers found that when clinicians had both a good level of awareness and the right training, they were much more likely to ask their patients what they wanted. The study also found that the best performance was in Denmark, where national health policy has emphasized patient satisfaction for the past decade.

Far from being a social nicety, patient expectations and satisfaction seem to matter on measures that really count. When expectations go unfulfilled, they are “associated with poorer satisfaction, low clinical guideline adherence and poor overall health outcomes,” the researchers wrote. “Consequently, a growing body of evidence supports the importance of identifying and addressing patients’ expectations.”

Do mammograms really save lives?

There’s a common belief that routine mammograms save lives – but do they really?

A provocative article appearing in the latest edition of the Archives of Internal Medicine examines this claim and concludes that the ability of routine screening to prevent women from dying of breast cancer has been overstated.

The authors’ rather startling summary: “Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.”

This is not a message most of us are accustomed to hearing. The benefits of routine screening for breast cancer have been drilled into virtually every American woman over the age of 20 or thereabouts, and reinforced with numerous, emotionally powerful stories of individual women whose cancer was detected during a regularly scheduled mammogram and who are alive to tell about it.

The article’s authors used DevCan, a software program developed by the National Cancer Institute for analyzing SEER )Surveillance Epidemiology and End Results) data to estimate women’s 10-year risk of a breast cancer diagnosis and 20-year risk of death. They crunched the numbers in several different ways: with mammography, without mammography, with varying statistical assumptions about risk reduction in breast cancer deaths, and for women at ages 40, 50, 60 and 70.

Their analysis found that among all age groups, fewer than 25 percent of women likely had their lives saved because of a screening mammogram. In many cases, the authors explained, “a woman may have had her breast cancer detected early yet not benefit from early detection because her cancer would have been equally treatable had it presented clinically… Alternatively, a woman may have been overdiagnosed – diagnosed with a cancer not destined to cause symptoms or death.”

There’s a caveat to this analysis. It’s based on a set of statistical assumptions rather than an actual group of women, hence comes with several limitations.

Nevertheless, it challenges the accuracy of one of the most widely held notions about screening and prevention: that women can reduce their risk of dying of breast cancer by having regular mammograms – and, conversely, that women who skip getting a mammogram are somehow irresponsible or are putting themselves at undue risk.

Screening and prevention in fact are not the same thing, a distinction that seems to have become lost in many of the public health messages, particularly when it comes to cancer. Nor does screening necessarily guarantee a good outcome; individual tumor biology seems to be the most critical determinant of whether a cancer will be slow-growing or metastasizing, whether it will respond well to treatment or become treatment-resistant.

It’s only been in the last few years that the public discussion has become more nuanced about the benefits of screening and early detection. For instance, health experts have backed away from routine screening for prostate cancer, citing the unreliability of the PSA test and the risk of overdiagnosis and overtreatment. Two years ago the U.S. Preventive Services Task Force recommended against routine mammograms for women in their 40s, citing the lack of a clear life-saving benefit and calling instead for this to be an individual decision between these women and their doctors.

This is an emotional issue for many people, though, and the authors of the Archives of Internal Medicine acknowledge the difficulty of squaring the science with women’s personal experiences:

Today, more people are likely to know a cancer survivor than ever before. Between 1971 and 2007, the number of cancer survivors in the United States more than doubled, from 1.5% to 4.0% of the population. Breast cancer survivors are particularly common: they now represent approximately 2.5 million, or one-fifth of the current survivor population. 

Earlier diagnosis (either via enhanced awareness or screening) and better treatment are clearly part of the explanation for this large survivor population. But so too is the enthusiasm for screening and the resulting overdiagnosis. And, ironically, this enthusiasm may, in turn, be the product of a large number of survivors. This self-reinforcing cycle (the more detection, the more enthusiasm — the so-called popularity paradox of screening) is driven, in part, by the presumption that every screen-detected breast cancer survivor has had her “life saved” because of screening. Our analyses suggest this is an exaggeration. In fact, a woman with screen-detected cancer is considerably more likely not to have benefited from screening. We believe that this information is important to put cancer survivor stories in their proper context.

Importantly, no one is saying screening is worthless or that we should all stop doing it. By the researchers’ own estimates, mammography does help save lives up to 25 percent of the time. But it seems to be a matter of recognizing that mammograms aren’t the silver bullet we’d like them to be, Dr. Susan Love writes in a column that appeared earlier this month at AOL Healthy Living.

When it comes to screening mammograms, we tend to engage in wishful thinking and ignore the science, she wrote. “We get angry at the experts who tell us studies show that mammography is less beneficial for women in their 40s. We focus on the idea that if only women had regular mammograms every cancer would be found early and cured.”

Rather than argue about screening guidelines, Dr. Love writes, “we need to face the science squarely and focus on prevention, so that we can learn how to avoid cancer in the first place.”

West Central Tribune file photo

Saved by the belt

If ever proof was needed that seatbelts help save lives, look no further than the Minnesota State Patrol’s online summary of crash reports.

The trend is pretty clear: Most of the fatal crashes involve victims who weren’t wearing a seatbelt. Crashes that result in minor or no injury generally are associated with seatbelt use, often with the added advantage of airbag deployment.

It would be hard to find a cheaper, easier or more widely beneficial public-health intervention than the seatbelt. The message seems to be sinking in with the public; seatbelt use in Minnesota hit an all-time high of 92.7 percent this year, according to an observational study carried out in 37 counties this past August by the Minnesota Office of Traffic Safety. The study’s results were made public this week.

A closer look at the data reveals some interesting details. Hands down, the group least likely to use safety belts was young men driving pickup trucks, a finding that also consistently shows up in national studies on seatbelt use.

Women and older adults had the highest rate of buckling up, regardless of which type of vehicle they occupied. Among all types of vehicle, vans and minivans scored best at seatbelt use by the occupants – 95.7 percent.

Reaching this level of seatbelt use has taken years. Back in 1986, when Minnesota’s mandatory seatbelt law took effect, the rate of belt use was only 20 percent. As recently as 10 years ago, approximately one-fourth of the state’s motoring public did not wear a seatbelt.

 State officials believe the primary seatbelt law, which took effect two years ago and allows law enforcement to pull over and issue a warning or ticket to motorists who fail to buckle up, has helped change at least some of this behavior. Of note, the number of Minnesota traffic fatalities among unbelted motorists has fallen by 10 percent since 2009, while the number of severe injuries has gone down 5 percent.

So why do some people continue to avoid using a seatbelt? When the National Highway Traffic and Safety Administration conducted a survey some years ago, the leading reason for not buckling up was “I’m only driving a short distance,” followed by “I forgot to put it on,” “I’m in a rush” and “Belt is uncomfortable.” Other reasons people gave: they didn’t want the belt to wrinkle their clothing, and they figured they were unlikely to get in a crash.

Another excuse that comes up is the belief that it’s better for the driver and passengers to be thrown clear of the vehicle in a crash. Statistically, however, you’re 25 times more likely to die if you’re ejected, and at much greater risk of being flung into the path of oncoming traffic or having the vehicle roll on top of you. As for the fear of being trapped by seatbelts in a burning or submerged vehicle, the safety restraints can help prevent serious injury and enable you to remain alert enough to escape.

If there’s room for improvement in Minnesota’s seatbelt use statistics, it’s among adolescents and young adults. This age group has historically had lower rates of seatbelt use, and it doesn’t seem to be an accident that they also have the highest rate of fatal crashes per miles driven. We don’t tend to think of traffic safety as one of the factors contributing to life expectancy, but it’s clear from the numbers that prevention and risk reduction strategies addressing seatbelt use do make a difference.

Photo: Wikimedia Commons

Blog break

New entries here will be rather sparse for the next two weeks while the blogger takes a long- overdue break. More frequent posting will resume at Halloween or thereabouts.

Readers are invited in the meantime to check out the archives and browse through some of the older posts. To get you started, here’s a selection of some that have been the most popular over the past three years.

– Readers seem to respond to blogs that are about food. “Deep-fried everything on a stick” was a blockbuster when it was published back in August, just in time for the Minnesota State Fair and its menu of deep-fried cheese curds, candy bars and cookie dough. There’s still hardly a day that goes by when I don’t get at least half a dozen site visits because of this entry.

– Anything to do with pets is popular too. I was a little late in stumbling across a study about the health hazards of sleeping with the family cat or dog (the study came out in January 2011 and I didn’t blog about it until a month later) but the topic was too good to pass up. Here it is: “Sleeping with the dog? Bad human!”

– One of the all-time most read posts on this blog explored the issue of marriage and its impact on health. “Wedding ring = better health?” You be the judge.

– I’m a little surprised at how often people continue to read “When the patient is a no-show.” This post was published in March 2010; well over a year later, it’s still generating site visits. I’ve even received a couple of emails (one of them from Finland) from people who are researching the topic of no-show patients and are looking for sources of more information.

– I had fun writing “That twin thing.” Part psychology, part popular culture and part personal experience, it was one of those posts that just wrote itself. (My twin sister enjoyed it too.)

– Speaking of popular culture, “Reality bites,” another ancient post from two years ago, still turns up quite frequently among my stats. Who knew five minutes of watching “Wipeout” would provide something to blog about?

– And to wrap this up, a couple more posts that have turned into the blog equivalent of frequent fliers: “Farmville, Angry Birds and other online compulsions” and a medical trivia quiz (the answers are posted here).

A dose of Midwest Nice

Apparently it doesn’t always pay to be polite.

A group of European researchers has reviewed the literature on the psychology of good manners and concluded that in high-stakes situations, politeness can lead to misunderstandings – or worse yet, to actual harm.

These rather intriguing findings appear in the October issue of Current Directions in Psychological Science, a journal published by the Association for Psychological Science.

According to the authors, there’s a time and place to be polite – when a friend is showing off a new outfit, for example, and you think it’s unattractive but don’t want to hurt her feelings by saying so. In such situations, being polite is a way of reducing the awkwardness and maintaining the friendship, the authors write.

They point out that we often resort to politeness when we have to communicate something that might offend or embarrass the other person or imply they’ve made a bad choice. The more sensitive the issue, the more likely we are to be polite.

Not that there’s anything wrong with this. “Politeness is obviously a very positive behavior in most cases,” one of the authors, Jean-Francois Bonnefon, said in an accompanying news release.

When it becomes a problem is in high-stakes situations that require clarity, the researchers said. They cite existing studies that suggest politeness can lead to confusion about what the speaker really means. Furthermore, it seems to take more cognitive resources to process the message. “We must think harder when we consider the possibility that people are being polite, and this harder thinking leaves us in a greater state of uncertainty about what is really meant,” the authors explain.

It’s not difficult to see how this ambiguity would spill over into conversations between patients and clinicians. What do you say to a patient who’s made an ill-judged decision to forego necessary treatment? How do you discuss the patient’s obesity or alcohol use or tobacco use in ways that are honest and realistic?

You could argue that when physicians soft-pedal the message by being polite, patients might not fully understand their risks or be motivated to make good decisions. A study that appeared last year in the Journal of Medical Ethics explored what the authors say is a deeper issue about physician politeness: that it “masks their existential neglect”  of the patient as a person.

On the other hand, patients generally prefer to be treated with respect, and they don’t always respond well to a dose of brutal honesty.

It doesn’t necessarily pay for patients to be polite either. I blogged awhile back about whether nice patients finish first. On the surface, it might seem they do – but when you examine the issue closer, it becomes clear that if “niceness” is equated with acquiescing to whatever the doctor recommends, it’s not always in the patient’s best interests to be docile and polite.

What can be done to reduce the chances that politeness will lead to misunderstandings or result in outright harm? The authors of the European study suggest encouraging people to be more assertive in high-stakes situations where it’s especially important to have clarity.

There could also be non-verbal cues, such as tone of voice, that indicate someone is trying to be polite, the researchers wrote. If these cues could be identified and if people could be trained to recognize them, it might make it easier to interpret polite statements with more accuracy and less confusion, they wrote.

Image: “The Cup of Tea,” Mary Cassatt, 1880

Pill City

You know your life is changing when the number of prescription medications you take each day begins to inch its way up.

It’s a fact that Americans pop a lot of pills. I recently spent a few minutes researching this issue online and made some rather eye-opening discoveries. A report issued last year by the Kaiser Family Foundation estimated U.S. spending on prescription drugs at $234.1 billion in 2008. According to the report, the number of prescriptions increased 39 percent – from 2.8 billion to 3.9 billion – during the decade between 1999 and 2009.

Here’s the statistic that was really surprising: In 1999 the average number of retail prescriptions was 10.1 per capita. By 2009, this had risen to 12.6 per capita.

Some of these undoubtedly were one-time medications, such as a course of antibiotics, rather than pills being taken 365 days a year. But when you consider that some people get by with one or two prescriptions a year (or perhaps none at all), it’s clear from the math that plenty of others are probably making up for it, and then some, with significant quantities of prescription medications.

A couple more tidbits from the Kaiser Family Foundation report: About 62 percent of American households have at least some prescription drug expenses annually. The likelihood of spending money on prescription medications goes up with age; 58 percent of Americans under age 65 had at least one prescription in 2007, but for those older than 65, it was 90 percent.

Is this a bad thing? Not necessarily. When correctly prescribed and taken, medication undoubtedly helps people manage asthma, allergies, depression, diabetes, high blood pressure, pain and more, allowing them to function and possibly sparing them – or at least reducing their risk – of more serious problems down the road.

But there’s a dark side to all of this. The prevalence of prescription drug use in the U.S. has given rise to polypharmacy, or multiple prescriptions that can increase the risk of unwanted side effects and potentially dangerous drug interactions, especially among the elderly. There’s also “prescribing cascade,” which happens when a prescription medication produces side effects, the doctor prescribes another medication to combat the side effects, which results in yet more side effects, yet another medication and on and on.

Adherence can become an issue as well. It gets complicated when someone takes a dozen prescription medications daily – some once a day, others twice a day, some with food, some without, some that can be taken together, others that can’t. It can be challenging to even remember a regimen like this, let alone stick to it day after day.

For all of the apparent emphasis on pills, many people don’t like taking them. In a study conducted a few years ago, researchers queried older adults about their prescription medication habits and found multiple reasons why these individuals didn’t always take their pills. At the top of the list was cost – but people also often cited concerns about side effects and drug interactions, or didn’t really believe the drug was necessary.

There were some rather strong reactions to a CNN story earlier this year that asked, “Are you taking too many meds?” One person’s comment: “Big pharma is one of the greatest contributors to the wreck and ruination of America.” (I noticed that very few of the commenters addressed the opposite question: Are you not taking meds that would truly benefit your health?)

The truth probably lies somewhere in a gray zone. In recent years there seems to be a trend toward being more thoughtful when prescribing drugs. There’s growing awareness, for instance, that statins to lower cholesterol may not be all that helpful to individuals who have no previous history of heart attack. More recently, the effectiveness of multivitamins for middle-aged women has been called into question. Evidence-based guidelines are forcing more consideration of when a drug is genuinely appropriate.

Most of us are unlikely to get through life without needing a few prescription medications along the way. It’s smart to ask questions to make sure a prescription drug is truly necessary, and smart to take it if the honest answer is yes.

Photo: Wikimedia Commons

Risky business

As I sat in a corner of the waiting room and perused the consent form, alarming words and phrases leaped out at me. “We cannot guarantee…” “… rare complications…” “… risk of death…”

It made me seriously wonder if I was making a mistake by subjecting my cat to anesthesia in order to have her teeth cleaned.

In the end, the risk seemed small and not enough to outweigh the benefits. But just the same, I handed her over to the veterinary tech with a pang of misgiving. Even a small risk doesn’t mean there’s no risk at all. If complications are going to happen, who says it won’t happen to you?

When you get right down to it, much of health care decision-making involves a series of calculated risks, a complex set of tradeoffs. This treatment for that benefit. This medication for a reduction in the chances of having a heart attack. These antibiotics, and the side effects that go with them, in exchange for getting rid of a bacterial infection. This conservative watch-and-wait approach vs. prompt and possibly unnecessary (and expensive) intervention. This risky surgery in hopes of saving the patient’s life.

Yet how we perceive risk vs. benefit often tends to be highly subjective. What some people view as reasonable might be viewed by others as too aggressive or perhaps not aggressive enough.

I’m eagerly waiting to get my mitts on Dr. Jerome Groopman’s latest book, “Your Medical Mind.” Co-written with Dr. Pamela Hartzband, it’s subtitled “How to Decide What Is Right for You” and explores how our beliefs, values and past experiences help shape the health care choices we make. (A review of the book appeared last weekend in the New York Times.)

Are you a minimalist who prefers to avoid procedures and pills unless they’re totally, absolutely necessary? Or do you believe in seeking out the latest technology or treatment that science can offer?

People can be unconsciously swayed by factors they might not even recognize – pharmaceutical marketing that plays up the effectiveness of a new drug, for instance, or a relative’s previous frightening experience with a surgical procedure that went awry. Over the years I’ve had other cats who had to be lightly anesthetized for a dental cleaning. They emerged a little bit woozy but were safe and sound and soon recovered. This helped reinforce that it was an acceptable risk to take. My perception might have been entirely different if I’d had the experience of losing a cat who stopped breathing under sedation.

We are not, in fact, entirely rational in how we assess our health risks. Via MinnPost, I came across an article from Discover magazine that delves into the conflict between our gut and our brain. Author Jason Daley describes how we fear rare threats while downplaying risks that are far more real:

A whole industry has boomed around conquering the fear of flying, but while we down beta-blockers in coach, praying not to be one of the 48 average annual airline casualties, we typically give little thought to driving to the grocery store, even though there are more than 30,000 automobile fatalities each year.

One of Daley’s points seems especially valid in the current health care environment: We tend to gravitate toward that which confirms the optimistic beliefs we already hold.

For an example of this, look no further than screening for prostate cancer. The screening is common, it’s widely thought by the lay public and many doctors to be beneficial in catching prostate cancer in its early stages, and the belief is that it saves lives. But when you look closer, it turns out that, statistically speaking, the survival benefit isn’t particularly strong. Furthermore, aggressive screening has led to overtreatment, side effects and complications among men who could equally well have taken a watch-and-wait approach – or skipped the screening altogether.

When we’ve long held the belief that prostate cancer screening saves lives, however, it’s a hard pill to swallow that this isn’t the intervention we thought it was.

There’s sure to be a storm of controversy this week when the U.S. Preventive Services Task Force formally issues a new recommendation against routine annual prostate cancer screening for older men. In fact, the controversy has already begun with salvoes fired here, here and here. It’s all very reminiscent of a similar firestorm two years ago when the USPSTF recommended against routine mammograms for women in their 40s, saying there wasn’t enough evidence to support that routine screening saves lives and that mammograms for women in this age group should be made after weighing the pros and cons with their doctor.

Life would be easier if health care decisions were straightforward: Yes, this intervention will help; no, this prescription won’t help. Emotions, values and individual health history, coupled with the actual evidence (or lack thereof), make for a complicated tangle of factors to consider. We seem to slowly be coming to a realization, though, that overtreatment is as undesirable as undertreatment, and that some risks pay off while others may not. Making health-related decisions is a risky business that deserves to be approached with as much rationality as we can muster.

Talking about depression

Depression doesn’t care if you’re well off or struggling on the lower rungs of the economic ladder. For better or worse, though, it often goes hand in hand with poverty – a fact that’s taking on increased significance as the global ranks of the poor continue to swell.

Here are some sobering findings from some of the data collected for STAR-D (Sequenced Treatment Alternatives to Relieve Depression), one of the largest studies in the U.S. on depression and the treatment of depression: Chronic depression is associated with unemployment, lower income, less education, lack of health insurance, lower quality of life and poorer overall health.

One of the big questions is which comes first. Do people develop depression because they’re poor, or do they become poor because of the toll depression often takes on human potential?

The burden of depression is no small matter. It’s one of the most prevalent mental health conditions in the U.S., affecting approximately one in every 10 Americans.

You’d think this would make the public more aware of depression and more likely to be able to recognize it and have it effectively treated. All too often, though, this isn’t the case.

Several years ago I visited with local mental health professionals for a story about a new initiative on depression and older adults. I learned a number of things – for instance, that here in the rural Midwest there’s a tendency to believe depression is a character weakness that can be fixed with a dose of stoicism and/or positive thinking. I also learned that when older adults develop depression, it’s frequently shrugged off as normal. Similar misconceptions apply to age and demographic groups across the board.

Given all of this, it was therefore both dismaying and enlightening to come across a recent study in the Annals of Family Medicine that explores some of the reasons why patients often don’t tell their primary care doctor that they’re struggling with depression.

The study, which involved about 1,000 adults in California, came up with some interesting findings:

– More than 40 percent of the respondents reported at least one barrier to asking their doctor for help with their depression. The most common reason: worries about being put on medication.

– Stigma appeared to be an issue for at least some of the survey participants. Fifteen percent didn’t trust the confidentiality of the medical record. Others feared being referred to a counselor or psychiatrist, or being labeled as a psychiatric patient.

– Those who reported the most barriers also were the most likely to have moderate to severe depression – in other words, they had the most to lose by not speaking up about their depression. People who are depressed may not be able to speak up, however – often because their capabilities are diminished or they don’t perceive themselves as competent, the study’s authors point out.

– Here’s one of the clinchers: Lower income and less education were associated with more, rather than fewer, barriers to disclosing depression to a primary care doctor.

The relationship between socioeconomic status and depression is no doubt complex and not fully understood. It’s pretty clear, though, that it exerts a significant undertow on society when it goes unrecognized and unaddressed.

You can learn more about depression by checking out the many links on the National Institute for Mental Health’s online resource center for information on depression or by visiting the Screening for Mental Health website, where you can complete an online assessment for depression.

Photo: Wikimedia Commons

In health and in sickness

I’m not really a fan of country music but I’ve been rather taken with Martina McBride’s new hit single, “I’m Gonna Love You Through It.”

The lyrics describe a relationship that endures through a cancer diagnosis with the promise that “when you’re weak, I’ll be strong; when you let go, I’ll hold on.”

Would that every couple could weather a health crisis with this much strength. For Diane Mapes, being diagnosed with breast cancer was bad enough. “But getting dumped by the guy you’re seeing right afterwards is sort of like finding a piece of spoiled lettuce on your crap sandwich,” Mapes wrote this week at

His parting shot to her: “It’s not cancer, it’s you.”

And nope, she’s not the only one to experience the cancer kiss-off. Mapes shares the story of Cindy Wine, a former radio show host, who came home from her first radiation therapy session to find the house empty of her husband and all his belongings. He sent her an email that night, telling her he just couldn’t deal with the stress of her illness.

Is sickness too much for some relationships to handle? Surprisingly, only a handful of studies have ever examined the likelihood of couples breaking up after one of them is diagnosed with a major illness. Most of them suggest that divorce is no more frequent among cancer patients than among the general population.

But one of the more intriguing studies, published in the Cancer journal in 2009, found that women with cancer or multiple sclerosis were more than six times as likely to be abandoned by their partner than when the man was the patient. Only 3 percent of the male patients in the study experienced divorce or separation, but 23 percent of the women did. Overall, 88 percent of the separations and divorces analyzed in the study took place when it was the woman who was the patient.

The argument that men bail out in the face of illness recently gained another jolt of ammunition from TV evangelist Pat Robertson, who last month suggested to a man whose wife was in the advanced stages of Alzheimer’s disease that he “divorce her and start all over again.”

What’s the deal, guys?

Mapes spoke to Dr. Marc Chamberlain of the Seattle Cancer Care Alliance, who was one of the authors of the study, and received this answer from him: “Men may be very well equipped to be primary providers but not so well equipped to be primary caregivers. I think men are challenged in caring for someone who has disease and treatment-related symptoms – managing the stress, managing the logistics.”

Another finding from the study: The length of the relationship also seemed to matter. Couples who had been together longer were more likely to stay together through a serious illness.

It’s entirely possible, of course, that the couples in the study who split up already had a rocky relationship, and the diagnosis of cancer or MS simply hastened the inevitable. It’s not clear whether this is the case because the study wasn’t designed to answer this question. Nor did the researchers attempt to determine which of the partners initiated the breakup.

But for some perspective on the whole issue, consider this: The vast majority of the couples in the study – 455 out of 515 – did manage to stay together. Many of them might actually have emerged with an even stronger relationship than before.

For better or worse, serious illness is a game-changer. This is difficult stuff, after all. Whether out of fear, guilt, confused priorities or lack of commitment, some people in a relationship simply are not up to the challenge. Does that necessarily make them bad, or does it just make them human?