The Grey Dog

I was once a moody child; I’m still a moody child… sorry, adult. Anyway, I’m also a bit sensitive about the topic. It’s as if being moody means being naughty, or maybe contrary. Not quite right in the head, or something -not well adjusted, at any rate. I take exception to that. I mean, just because I often have trouble mixing with people at parties who only want to make small talk -usually about other people- and then walk away shouldn’t disqualify me from church or anything… Okay, I don’t go to church, but you see what I’m driving at, I hope. Moods are kind of baroque frames around my happiness. They make even run-of-the-mill joy look like ecstasy.

I’m not advocating ignoring the more severe and persistent forms of mood -they may in fact herald something very important. I am saying that not all of us who are occasionally disgruntled, frustrated, or unhappy have some underlying pathology. And to label those occasions as bouts of depression is to dilute the word, mistake the condition, assume everything is the black dog.

I was therefore relieved to find someone who relates to that view:  https://theconversation.com/is-my-child-depressed-being-moody-isnt-a-mental-illness-92789

The author, Dr. Stanley Kutcher, Sun Life Financial Chair in Adolescent Mental Health, at Dalhousie University, Begins by noting that, ‘[…] if the media coverage is to be believed, we are drowning in a sea of mental illness that threatens to overwhelm post-secondary Institutions. […] The prevalence of mental illnesses (defined using clear diagnostic criteria) is not rising in this cohort.

‘Youth self-reports of negative emotions are increasing. But the self-report scales used in studies documenting this have not been calibrated for generational changes in language use. Nor have the results been validated using clear, clinically valid, diagnostic criteria applied by expert clinicians.

‘[…] The above noted self-reports do identify the ups and downs of everyday emotions, but these are not criteria for diagnosis of mental illness. So we can say that youth on campus may report feeling more negative emotions than previously, but this is not the same thing as saying that young people have more mental disorders than previously.’

He cites an interesting example of the lack of application of basic critical thinking and analysis: ‘In late 2017, the study “Mental ill-health among children of the new century: Trends across childhood with the focus on age 14” was published by the National Children’s Bureau in the United Kingdom.

‘This showed that self-reported negative emotions were present in about one quarter of this surveyed group, but this was interpreted as 25 percent of 14-year-old girls in the UK suffer from depression! The fact that parental reports identified about five per cent of this cohort as having significant mood problems was ignored by almost all commentators. This latter number is much more in keeping with known rates of depression in the population.’

I wonder if our expectations of normalcy are to blame. As Dr. Kutcher explains, ‘These concerns are not the result of substantial epidemic increases in the rates of mental illness. They arise, in some part, from poor mental health literacy and unrealistic expectations of the normal emotional states that life challenges elicit.’

He makes some interesting and important points, I think. ‘[…] First, the increased public perception that being well means only having positive feelings is taking over the social discourse on mental health. When the measure of health is simply feeling good, negative emotions become a marker of being unwell. […] Without addressing the life challenges and opportunities that negative emotions signal to us, we can’t develop resilience. Mental health is not a static concept wearing a big smile. There are good days and bad days, good weeks and bad weeks. We still have mental health even if we are having negative emotions.’

‘Second, the use of words originally developed to identify mental illnesses to describe normal negative emotional states has burgeoned. […] Further, the use of terms denoting illness, such as depression, to mean all negative emotions is even more confusing. Now, words like sadness, disappointment, disgruntlement, demoralization and unhappiness are all lumped together as depression.’

He feels that the continued and almost obsessive use of technologies like smart phones for communication-especially by the young- may limit their ability to express complex messages and ideas and hence increase the sense of isolation, of being misunderstood -or perhaps, of even being mislabelled. And since it is adults, by and large, in charge of the classifications, it’s almost a case of two solitudes, two Magisteria, staring at each other -neither the wiser. Neither the winner…

Interestingly, I think I caught a whiff of this while waiting for a bus the other day. Two quite young teenage girls were sitting on the only bench in the little shelter, both clutching their mobile phones like purses. Because the rest of the bench was filled with their back-packs and some school binders, I merely stood outside and leaned against the wooden frame.

“But what did he say, Kitty? Is he, like, mad at you or something?” This from a petite little girl with long, straight dark hair and a big red coat with only a pair of blue boots sticking out from the bottom.

Kitty shook her head and leaned back on the wall of advertising behind her. She also had dark hair, but short and messy. It fit rather well with a large, thick and ragged blue sweater, torn on at least one sleeve to show a thin arm underneath. Her jeans were also fashionably torn, but looking as new as her pink running shoes. “No… Not mad… Just, like, upset. He says I’m moody -and all because I don’t want to, like, talk with him and Mom at the dinner table. I mean, nobody, talks anyway.” She shrugged theatrically and leaned forward on the bench again.

Her friend sighed sympathetically. “Yeah, my mom keeps wanting me to… you know, like communicate with her, too. But I mean, ever since dad left, she’s always either on her phone, or has the TV on.”

Kitty, nodded. “Yeah well, like, my parents think I should see a counsellor at school… They think I’m depressed, eh?” Her friend’s expression tightened, but she stayed silent. “But my dad always has his phone on the table and, like, keeps glancing at the news on his apps or, like, he’s waiting for an important Email, or whatever. And my mom’s a realtor, remember, so she does the same.” Kitty glanced around the wall and saw a bus was coming. “That’s all they talk about, anyway, Jen.”

Jen was staring intently at the ground in front of her. “Well, I think my mom’s depressed, you know, but she won’t go see anybody about it.” She took a little stertorous breath. “She thinks she’s coping… But I think, like, she’s just escaping online and stuff…”

The bus pulled up, and Jen seemed on the verge of tears, so Kitty reached over and hugged her. “We have to be strong for them, you know, Jen…”

That’s all I heard before they quickly gathered their things and walked over to the bus, arm in arm. Kitty must have whispered something else to her, because they both started to giggle before they got on.

I don’t know if it’s the technology, but it did make me wonder whether we really have a handle on mental health yet.

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What is the Merit of Originality?

‘I am not young enough to know everything,’ as Oscar Wilde once said, and maybe the rest of us aren’t either. It is often an unquestioned assumption that New trumps Old, that innovation usually leads to improvement, and that by standing on the shoulders of giants, the view is necessarily better. Clearer.

But there is wisdom in both the long as well as the panoramic views. Neither changing  your shoes nor altering your hat, really improves the safety of a voyage -nor does it address the original goal of a safe arrival of everybody on board. Appearing modern, seeming prepared, only helps if it helps –a leak is still a leak, especially if there are only lifeboats for a few…

Let me explain. I happened upon an article in the journal Nature that chronicled the introduction of a new, and highly accurate method of diagnosing TB through genetic analysis.  https://www.nature.com/news/improved-diagnostics-fail-to-halt-the-rise-of-tuberculosis-1.23000?WT ‘The World Health Organization (WHO), promptly endorsed the test, called GeneXpert, and promoted its roll-out around the globe to replace a microscope-based test that missed half of all cases.’ It sounded like a perfect technological fix for a disease that has so far avoided effective control. ‘Some 10.4 million people were infected with TB last year, according to a WHO report published on 30 October [2016?]. More than half of the cases occurred in China, India, Indonesia, Pakistan and the Philippines. The infection, which causes coughing, weight loss and chest pain, often goes undiagnosed for months or years, spurring transmission.’

Unfortunately, ‘[…] the high hopes have since crashed as rates of tuberculosis rates have not fallen dramatically, and nations are now looking to address the problems that cause so many TB cases to be missed and the difficulties in treating those who are diagnosed. […] The tale is a familiar one in global health care: a solution that seems extraordinarily promising in the lab or clinical trials falters when deployed in the struggling health-care systems of developing and middle-income countries. “What GeneXpert has taught us in TB is that inserting one new tool into a system that isn’t working overall is not going to by itself be a game changer. We need more investment in health systems,” says Erica Lessem, deputy executive director at the Treatment Action Group, an activist organization in New York City.’

But I mean, just think about it for a minute. ‘The machines cost $17,000 each and require constant electricity and air-conditioning — infrastructure that is not widely available in the TB clinics of countries with a high incidence of the disease, requiring the machines to be placed in central facilities.’ Sure, various groups agreed to subsidize the tests in 2012, but: ‘each cost $16.86 (the price fell to $9.98), compared with a few dollars for a microscope TB test.’ So which test would you choose if you were a government strapped for cash to provide for healthcare for a broad spectrum of other equally pressing needs?

‘Even countries that fully embraced GeneXpert are not seeing the returns they had hoped for. After a countrywide roll-out begun in 2011, the test is available for all suspected TB cases in South Africa. But a randomized clinical trial conducted in 2015 during the roll-out found that people diagnosed using GeneXpert were just as likely to die from TB as those diagnosed at labs still using the microscope test.’ That seems counterintuitive to say the least.

So what might be happening? ‘Churchyard [a physician specializing in TB at the Aurum Institute in Johannesburg, South Africa] suspects that doctors have been giving people with TB-like symptoms drugs, even if their microscope test was negative or missing, and that this helps to explain why his team found no benefit from implementing the GeneXpert test. Others have speculated that, by being involved in a clinical trial, patients in both arms of the trial received better care than they would otherwise have done, obfuscating any differences between the groups.’

‘Even with accurate tests, cases are still being missed. Results from the GeneXpert tests take just as long to deliver as microscope tests, and many people never return to the clinic to get their results and drugs; those who begin antibiotics often do not complete the regimen.’ Clearly, technology alone, without an adequate infrastructure to support it –without a properly funded and administered health care system- is not sufficient.

And it’s simply not enough to have even a well-funded health system that benefits just those who can afford it, leaving the rest of the population to fend for itself, and only seeking help when they can no longer cope –often when it is too late. Health care is a right, not a privilege –no matter what those in power would have us believe.

I’m certainly not arguing that improving technology is not part of the solution, but sometimes I wonder if it is merely putting new clothes on a beggar. Handing out flowers in a slum.

Let’s face it, real Health Care is more than a sign on a door, more than a few people in white coats. It is a kind of national empathy. A recognition that even the poorest among us, have something valuable to contribute; that even those who have strayed from society’s chosen path, are who any of us might be, but in different clothes.

The myth of Baucis and Philemon tugs at my memory: They were an old married couple living in a small village in Anatolia (part of Asian Turkey nowadays) who, unlike everyone else in the town, welcomed two peasants at their door who were seeking refuge for the night. The couple, of course, were unaware that they were actually welcoming two gods, Zeus and Hermes, disguised as humans. A common enough trope, perhaps, but an instructive one, I think -one that transcends virtually all cultures, and borders: the idea of helping others without any expectation of reward. It is not an exchange -a transaction- so much as an action. Agape, in fact.

Health care is like that. Or should be… It’s not about the glittering display in the shop window –there to impress the passersby- it’s about the people in the shop.

 

 

 

 

 

 

 

 

 

 

 

 

 

Whether ’tis Nobler in the Mind

I may have inadvertently stumbled upon something important. I may have found a boundary marker that potentially distinguishes New Age from Old Age. Of course, definitionally I could be way out of my league –New Age being construed as anything that happened after I left university- but considered as a panoply, I think it works, if only conceptually.

I happened upon an article in the CBC news app while scrolling through my phone, that struck me as interesting: http://www.cbc.ca/1.4302866 -perhaps because I had never thought about technology in those terms, and perhaps because I felt embarrassed that I had been caught doing just that.

The premise was that we seem to turn to various apps on our devices for problem solving of many sorts. Everything from comparing shopping prices to trends in fashion to the latest news. And, as we are increasingly discovering, these digital peregrinations revisit us in the form of directed advertisements hoping to cash in on our whimsical journeys. Nothing is thrown away in the digital world –even our whims are stored, categorized, and pragmatically redistributed. And if notions, then it seems a small step to include moods. Emotions –positive, or otherwise- should be equally trackable.

In fact, I learned that ‘Google announced it now offers mental-health screenings when users in the U.S. search for “depression” or “clinical depression” on their smartphones. Depending on what you type, the search engine will actually offer you a test. […] And Facebook is working on an artificial intelligence that could help detect people who are posting or talking about suicide or self-harm.’

Perhaps this is where I feel the shadow of a boundary issue. There seems little question that mood disorders transcend age and gender; what is more problematic, however, is whether there may be a generational divide in confiding those emotions digitally, or even believing that solace could lie therein. The problem is not so much in putting these issues in writing –diaries, and correspondence, after all, have long been a rich retrospective source for biographers. The difference, it seems to me though, is the intent of the disclosure –diaries have traditionally been personal, and usually, not meant as a way of communication, but rather a way of sorting out thoughts. Private thoughts. Letters, as well, were directed to particular individuals –often trusted confidants- and not meant for publication outside that circle. Have the older generation –Generation R, for example (Retirement, to attach a label)- been sufficiently swept up in the digital river, to feel comfortable in clinging to its flotsam like their children?

I’m certainly not gainsaying the efforts of the internet giants to expand into the mental health realm –it seems a natural progression, so perhaps this is a start… and yet it’s one thing to key in on various words like ‘depression’ and have the algorithm kick in with a screening test, but another to sift through the context to determine the appropriateness of offering the test. I suppose random screening like that may be helpful for some, but as Dr. John Torous, the co-director of the digital psychiatry program at Harvard Medical School and chair of the American Psychiatric Association’s workgroup on smartphone apps, observes, ‘”One of the trickiest things is that language is complex … and there’s a lot of different ways that people can phrase that they’re in distress or need help.”’ Amen to that.

Quite apart from translational difficulties and the more abstract and culturally-fraught issues with their changing metaphors and societal expectations, there are other language problems –even in the dominant language of whatever country: changing vocabularies, local argot, and misspellings, to name only a few.

To state that human culture is complex, is a trope, and to believe that artificial intelligence will be able to keep up with its multifaceted, ever-changing face, anytime soon is probably naïve. And, as the article points out, privacy –no matter the promises of the internet provider, or the app-producer- is another weak link in the chain. Quite apart from malicious hacking, or innocent and trusting confidence in the potential for help, ‘Our phones already collect a tremendous amount of personal data. They know where we are and who we’re speaking and texting with, as well as our voice, passwords, and internet browsing activities. “If on top of that, we’re using mental-health services through the phone, we may actually be giving up a lot more data than people realize,” Torous says. He also cautions that many of the mental-health services currently available in app stores aren’t protected under federal privacy laws [at least in the United States], so you’re not afforded the same privacy protections as when you talk to a doctor.’

In a very real –if mainly age-related- sense, I am relieved I did not grow up in the digital age. I am fortunate that Orwell’s prescient ‘1984’ was available, not as a quaint attempt at predicting the future, but as a warning about a creeping surveillance that seemed so malevolently unrealistic when it was written –it was first published in 1949, remember. And when I read it, the date was still sufficiently far in the future that it seemed more science fiction than predictive. Yet, as the years wore on, and society changed in unexpected ways, the horrors of the theme, for me at least, became more and more uncomfortable. More and more possible, despite the reassuring smoke blown in our eyes by those eager for progress, and mesmerized by the possibilities.

I mention this, not to suggest that I was unique in this discomfort –I was obviously not- nor to imply that what we are now experiencing is evil, or even threatening, but merely to explain the hesitation of many of those my age in accepting, unreservedly, the digitally-wrapped gifts so readily proffered. It is not a venue to which I would likely turn for health issues, or emotional sustenance.

For me, there is something more reassuring about an eye-to-eye encounter with another member of the same species, able to understand the vagaries of language, and compare the nuanced phrasing of my words with the expression on my face. Perhaps, I’ll change -perhaps I’ll have to- and yet… and yet I’d still feel better dealing with an entity –a person– able to experience the heart-ache and the thousand natural shocks that flesh is heir to. And yes, someone who has read and understood what Shakespeare meant.

The Black Sewing Box

I love mysteries, and if they involve finding buried treasure, so much the better. Thoughts of treasure chests used to conjure up maps and pirates hiding valuable things in faraway and largely inaccessible places. I suppose that shows my age, because nowadays, the more likely proxy for a treasure chest in the popular imagination is a flight data recorder –a black box- submerged beneath thousands of meters of ocean or buried under rocks on the side of a faraway mountain. Hidden wealth for sure.

The myth of faraway, or at least elusive, treasure is an ancient one; think of the Greek myth of Jason in quest of the Golden Fleece -the golden wool of a ram which symbolized authority. There is something enticing about that which we do not have, but might obtain with sufficient diligence. And information seems to be the treasure most prized in the modern era. Information is Power. Information is Knowledge.

And yet, despite the cache of data contained in the almost magically endowed black box, and despite its reputation as the only solution to an otherwise insoluble problem, we forget its other, earlier, and less forthcoming incarnation –its perhaps even more obscure aspect. In computational and engineering models, a black box is something we can use, but don’t understand. For every input, there is an output, but like a magician’s sleeve, we don’t know why. The brain is still a black box. You and I are, for all intents and purposes, black boxes. And that is what is so appealing to me: that none of us are completely knowable. Predictable. We are all magician’s hats…

A short article in an August 2015 Canadian Medical Association Journal stirred the coals of my easily invoked imagination: http://www.cmaj.ca/content/187/11/794.full  It likens the measured parameters in an aviation ‘black box’ to a research project involving operating rooms at a Toronto hospital. ‘The technology involves several cameras and microphones, along with sensors to document physiological data and key aspects of the environment, such as temperature.’ But this foray into the sacred chambers of the OR is not merely another frivolous time-and-motion study, so beloved of factories and corporations everywhere. No, as the article puts it: ‘The intent of the new technology is to enhance health team performance, pinpoint errors and missteps (human and otherwise), and subsequently identify ways to prevent and address those issues.’

Having spent a good part of my career as a surgeon in the OR, I appreciate the need to improve performance and prevent mistakes. In a teaching hospital, much of our time in surgery goes to passing on our skills and honing the competence and judgement of the resident doctors in the program. We become the monitors. But, as hinted in the old fable of mice deciding that the best way to detect the approach of a cat would be to hang a bell around its neck, who will bell the cat? In other words, how do we know that the surgeon –or whoever- is not passing along bad habits? Faulty techniques in need of improvement?

One way tried in recent times, has involved having another surgeon in the OR as an observer. A later meeting to debrief and discuss opportunities to modify identified issues then helps to improve performance. Unfortunately not all of us are open to suggestions about our skill-sets, and other opinions are sometimes seen as criticisms. Ego and the fear of loss of reputation likely figure prominently in the equation even though the findings are kept private. Only if this practice of observation and subsequent discussion were made universal would it have a chance of thriving as a learning tool, however.

Another, although for some, equally uncomfortable method of improving performance in the OR, would be the practice of having a more junior surgeon, say, scrubbing with another more experienced colleague as part of a mandated hospital policy for quality assurance -much as hospitals now require yearly performance and outcome reviews for hospital reappointment. Personally, I like this approach. It is an easy way to learn and see new techniques in a less stressful environment than if I were in charge of the case. And I think we can also learn from the residents we are teaching who have studied in other hospitals and with other surgeons. There are many ways to improve our skills if we don’t allow ourselves to become encased in habit and focussed only on our own clothes. As Isaac Newton might have put it, ‘If I have been able to see as far as others, it is by standing on the shoulders of colleagues.’ Well, okay, perhaps he said it better, but our options to improve seem to be either carrot or stick.

There is a trend creeping into public media of assessing and rating doctors on their outcomes. How many patients benefitted from the surgery? How many had complications? How many surgeries has the doctor performed? What about her colleagues? The publication of these data sets may seem reasonable, but unfortunately they leave many contributing factors in the shadows –or even unreported. Unconsidered. For example, perhaps the surgeon in question has a high complication rate because, as the most experienced, she gets the most difficult cases -maybe the ones that have failed other treatments.

All things considered, perhaps the black box approach has more compelling merit than first meets the eyes. If the public were assured that procedures were monitored and recorded this might go a long way to assuaging their suspicion of incompetence or malpractice. And as the article suggests, ‘Data recorded by the black box system could well speak for patients unable to speak for themselves because they were under anaesthesia or unfamiliar with hospital procedures and protocol.’ Let’s face it, ‘black box’ monitoring certainly helps to instill a level of confidence in airplanes: just knowing that after a difficult or problematic flight, experts could discover what actually happened and correct it for the future.

There is a problem with the black box method, however –an obvious one for surgeons: ‘the data in an operating room black box could be used as evidence in medical malpractice suits unless precluded by legislation — in much the same way morbidity and mortality assessments made by hospitals and staff for the purpose of quality assurance and improvements are exempt from being used in court.’ We all learn from our mistakes –and from the mistakes of others. We must, otherwise the errors will be repeated. And most of these issues are not the result of malpractice or incompetence. They are potentially teachable moments, if you will.

In fact, one lawyer commenting on the black box idea, felt that ‘the data could also help surgeons who are being sued. “With the black box, critical procedures and techniques could be objectively assessed by peer surgeons when a poor outcome occurs. From the surgeon’s point of view, the data would be confirmation that all was done right but the poor outcome was beyond their control.”

So, in a way, it’s prudent to swallow unsweetened medicine now to ward off disease down the road. In the words of Tolkien, ‘It will not do to leave a live dragon out of your plans, if you live near one.’