Riffing off A Powerful Message

A week’s worth of (medicated) sleep, and my noggin can at least process a few thoughts, here and there. 1 boring old man published an important post titled, A Powerful Message.  He chronicled the increasing clamor of psychiatry to use a neural circuitry model as evidence of psychopathologic causality and therefore an avenue for research and treatment.  I had noticed this, too, with increasing alarm and a sense of deja vu. I yammered a bit in a comment:

As a long time critical care nurse and educator, I witnessed an enormous transition in thinking about the care and treatment of myocardial infarctions (heart attacks). Care and treatment initially and historically was focused on complete bed rest and inactivity – up to and including only allowing room temperature food and drink lest cold irritate the vagus nerve. As the plumbing and electrical circuitry interface with the muscle stimulation and perfusion became more well known, treatments became more aggressive – getting patients up and moving right away, reperfusing coronary arteries and stenting them, ablating lesions, etc. Then the focus spotlighted statin use for prevention, concomitant with pharma DTC advertising and KOLs. Only recently has any of this been questioned, and lo and behold, stenting and preventive statin use may not do anything at all in terms of disease prevention.

Not for nuthin’ has clinical depression been found to coexist and correlate with heightened morbidity and mortality with of heart disease.

Patient stays in critical care units for heart attacks (MIs) went from 7-10 days to 1-2. Of course, patient education, diet teaching, stress management, socioeconomic assessment went out the window. In other words, self management and quality of life factors were ignored and abandoned. Patients are sent home with prescriptions, stents, pacemakers, automatic internal defibrillators and all manner of coronary hardware, and sometimes followup appointments. They are not linked to case managers, community resources and psychosocial supports.

The forces of capitalism, free markets and decreasing corporate regulation have converged to erode worker protections, environmental protections, food safety, community development (corporations receiving tax breaks, outsourcing jobs to other countries and pulling up stakes, leaving communities dying on the vine), and overall, contributing to the deterioration of social life and community throughout the US.  Vicious and poisonous politics have contaminated the well of civil discourse.

Whither health and well-being?

Here, my collegiate roots show.  Case Western Reserve University’s Frances Payne Bolton School of Nursing and the Department of Nursing Education, Teachers College, Columbia University, both were founded on the critically important work of nurses who established, grew, and nurtured public health and psychiatric nursing theory and practice.  My education was based on the principles and practices of Lillian Wald, Hildegard Peplau, Virginia Henderson, Isabel Hampton Robb (yes, the Robbs of Johns Hopkins and later, Lakeside Hospital of Case Western Reserve – this hospital was noted by Flexner in his famous Report on Medical Education, for serving as an exemplar), and Mary Adams, pioneer in gerontologic nursing and later a Dean at her home state, South Dakota’s State University School of Nursing.  These names will mean nothing to almost all members of the public, physicians, and sorry to say, nurses.

But I hope you’ll click on the links because their work has critical importance and influence on the individual, family and community health and well-being of Americans today. What you will see is their universal concern with the immediate and larger social and community environments which affect health and well-being of the targeted patient populations.

Physicians, nurses and indeed, all members of the (licensed, ergo, regulated) helping professions have an obligation to address, influence and lead policy and programming which are congruent with and supportive of a healthy environment and social life.  Those include wages which allow adults to work a single job and provide for safe shelter, clean water and air, nutritious fresh whole foods, reliable transportation, access to education and natural recreational facilities and adequate protective clothing for themselves and dependents.  It means assuring clean air and potable water.  It means assuring access for all to basic communicable disease prevention: vaccines, safe food, zoonoses prevention.  It means worker protections which promote tolerable physical and psychological stress levels.  It means protections for whistleblowers – rewarding workers for upholding ethical business, research and professional ethics.  It means promoting civil discourse and discouraging ostracism – whether that be racism, bullying, intimidation or any other type of behavior which is exclusionary.

Embracing the classical virtues and publicly upholding the inherent worth of every person will lead more to health and well-being than any pill, potion, invasive treatment or state of the art assessment tool.

The bottom line:  Each and every member of a helping profession by the social contract is an agent for social change.  Without that, patient treatment is devoid of care. And treatment will only palliate and blunt symptoms, rather than address disease and distress causality. Futile, impotent and, ultimately, destructive. Like this, perhaps:

Advertisements

We’re # 1? Nope – #38 and dropping

What does overall life expectancy have to do with upstream distressors?  This BBC article does a good job at listing many of the ills that result from US style westernized culture.

Risk factors

Source: University of Washington

Unsurprisingly, many of the risk factors tend to be behaviors which involve  self-medicating and self-soothing for perceived stress, anxiety and depression.  Some are related to living in poor quality neighborhoods lacking accessible and affordable fresh whole foods and green natural spaces to walk, sit, play and socialize.  Some are results of poor work and school environments, where long periods of enforced near immobility induce ill health.

All of the listed risk factors are malleable, modifiable and can be replaced with healthier choices.  But some of those alternatives needs must be supported by national, state and local policies and funding.  Fat chance of that happening in Tea Partier America.

Scientific American must have been channeling along the same lines in its Myths piece.

Myth #3 speaks to the notion that access to healthcare is a primary determinant of health.  Not so.

Access to health care is only one of several factors that play an important role in determining how healthy people are. Several studies suggest that easily being able to obtain medical care does not play as big a role as education, lifestyle, income and modern housing, along with sanitation (pdf) and vaccinationin determining why some folks are healthier than others.

Where the availability of health care makes the biggest difference to the health of any group is when people have regular access to general or primary care clinicians, who are able to take care of most of the medical problems people face most of the time. Good nursing care is particularly important for people with multiple chronic conditions.

What’s therapeutic about that?

The environment about where people are assessed and treated when experiencing a crisis of distress is critical.  Two bloggers recently addressed how much of a difference in help and harm leading to very different outcomes the physical treatment environment made here and here.

A recent post on the Bipolar Advantage blog discusses how to better help people during mental health crises, and proposes that “much of the hostility that [people who are part of the anti-psychiatry movement] have comes from bad experiences when in crisis.” I would absolutely agree.

When John had to enter the hospital a second time two weeks after his first, week-long stay, it was a real struggle to convince him to go because his first experience in the hospital had been such a negative one. I, on the other hand, have only gratitude for the people who helped me during my hospital stay.

It seems to me that mental hospitals could learn a lot about how to handle mental crises from the way general hospitals handle physical emergencies.

Many of the examples included actions by physicians and nurses that escalated and increasingly distressed patients already critically distressed.  In a comment on the Bipolar Advantage post, I summarized the desires of commenters in designing a helpful environment:

  Essential needs:

Dignity protected
Respectful
Family/significant supporters’ unrestricted presence
Advocate present
Comforting
Reassuring
Coaching
Partnering
Truthful and transparent information
Autonomy preserved
Planning for post-crisis self-management
Safe medication administration (right drug, right dose, right route,  right time, affordable, accessible, acceptable)
Tools for successful disease management and healthy living provided

Environment:

Medically therapeutic
Eliminate law enforcement/incarceration/containment aspects
Clear written rules – same as hotel room/gym/spa rules of conduct –         NOT  punitive/control/power-based

Health:

Healthful foods served appealingly: open kitchen
Privacy for rest and sleep
Ability to get sun, green space/nature and fresh air as desired
Meeting rooms and lounges for care, socialization, quiet activities (meditation/exercise/reading/contemplation) and care planning
Clean, attractive and non-odiferous patient care areas

That doesn’t look like to much to ask. In fact, it looks like the run of the mill hospital quality standards for every other service except psychiatry.

Self management strategies: Bicycling

Self-management and self-mastery strategies and lifestyle activities are protective against distress.  To that end, when I run across evidence supporting them, I’ll address them here.

The NYTimes produced an excellent column about the many diverse benefits of bicycling. Individual health, reduced particulate pollution, decreased motor vehicle infrastructure burden and economic advantages are all addressed.

Yet cars impose major social costs: their use contributes to global warming, traffic congestion, accident fatalities and sedentary lifestyles.

Bicycle use is good for both people and the planet. In a country afflicted by obesity and inactivity, people who get moving become healthier. Riding a bike to work or to do errands is far cheaper than joining a gym. Cutting back on gas consumption improves air quality, reduces dependence on imported oil and saves money.