Guest Post from Eric Stevenson: Caring for a chronic illness patient: A difficulty on its own

This Guest Post is from Eric Stevenson, a health and safety advocate who resides in the South Eastern US.

Having a chronic illness can be extremely tough, not only for the patient themselves but also for those who care for them. The process of loving and supporting someone with a chronic illness can be very difficult and challenging. Many times caregivers don’t want to speak up about their own stress because they may feel guilty or that it doesn’t matter as much than the patient’s problems. Luckily, there are a few ways to be prepared and help in the difficult situation of caring for a person with a chronic illness. 

There’s a great amount of social factors and possible coping strategies involved with care giving, as some things can influence stress levels in a positive or negative direction. Financial instability can cause major stress and mental issues for caregivers. In many times a chronic illness can lead to major financial problems as hospital bills continue to stack up. Financial factors can influence the mental state of caregivers in either direction. With more financial support, caregivers are often able to delegate some of their responsibilities, thus lowering stress and improving mental health. 

Social support also plays a huge role in the process of caring for a chronic illness patient. The help of family, friends, or even neighbors can play both a positive and negative part in the mental state. Not allowing for any support for the patient can often cause problems, but so can minimal support for yourself or a care giver. The stress and difficulty of taking care of someone with a chronic illness can be a major burden. Not having anyone to talk to or vent is often a major cursor to stress. 

Many people deal with side effects of coping strategies. Some may take to avoidance, but in many cases that will lead to further health problems. Avoidance as a coping strategy has been known to bring on many cases of depression. Many caregivers with low self esteem will use emotionally charged coping strategies, while those with high self esteem may turn to task centered coping methods. In the end, research has shown a large connection in self esteem and depression within caregivers. 

Factors such as the type of illness and location will also play a large part in the process. Some diseases like mesothelioma (a cancer forming from asbestos exposure) will have a severely low life expectancy. When compared to a patient that may be expected to live many years longer, the care giving situation will be extremely different. 

In the end, there are certainly a few factors that will play a large part in the role of a caregiver for those with chronic illnesses. The value of a support system and being educated on the disease will remain important. Caring can end up being extremely difficult and stressful, thus caregivers should also be looked out for in the future.

Meditation: Does it Do Anything?

Meditation sounds like a great idea from the perspective of a psychiatrist: anything that calms and focuses the mind is a good thing (and without pharmaceuticals: even better!).

Personally, I tried Transcendental Meditation as a kid...more to do with my mother than with me...and found it to be boring. I have trouble keeping my thoughts still. They wander to what I want for dinner and should I write about this on Shrink Rap and will Clink and Victor ever eat crabcakes with me again and did I remember to give my last patient informed consent and a zillion other things. Holding my thoughts still is work.

The New York Times Well blog has an article on Meditation and Brain Changes. In "How Meditation May Change the Brain," Sindya N. Bhanoo writes:

The researchers report that those who meditated for about 30 minutes a day for eight weeks had measurable changes in gray-matter density in parts of the brain associated with memory, sense of self, empathy and stress. The findings will appear in the Jan. 30 issue of Psychiatry Research: Neuroimaging.

M.R.I. brain scans taken before and after the participants’ meditation regimen found increased gray matter in the hippocampus, an area important for learning and memory. The images also showed a reduction of gray matter in the amygdala, a region connected to anxiety and stress. A control group that did not practice meditation showed no such changes.

-------Lower stress, lower blood pressure, higher empathy.... I may have to give meditation another try. The cartoon above, by the way, shows Roy leading a meditation session. Now there's a thought.

Why Am I Asking All These Questions?

I'm reading a book where the shrinky author starts off with a revelation: it's not the best care to see patients for a 50 minute evaluation, start a medication, have them come back in a month for a 15 minute med check, and refer them to a social worker for psychotherapy. It does sound like a good way to make a lot of money. If you aren't totally exhausted, overwhelmed with the phone calls and paperwork you must have seeing that huge a case load, and are someone who is gratified from this type of work, then it's cool by me. It's not what I want to do.

The author trained at about the same time as I did, and trained at an institution with a biological orientation, like the one I trained out. He talks about this kind of care as though it's standard and the usual and expected. I've never heard this as standard, and in my private practice, I see new patients for 2 hours, and want people to come back weekly for 50 minute sessions until -- they are no longer symptomatic, or they've gotten what they want out of the treatment. Some people come into treatment without symptom---their old shrink moved or died, and they just want a script and someone to rely on if they get sick. I don't insist they come every week, but I'll ask them to come more frequently than they are used to coming for a little while until I feel like I know them. Some people can't afford weekly psychotherapy or find it to be a burden, and I often respect their wishes to come less frequently, unless their illness is destroying their ability to function, in which case I think they need to come weekly. I don't see anyone more than once a week (unless there is an emergency) routinely, and I never seem to have patients who come requesting twice weekly therapy sessions. Almost everyone comes for the full 50 minute session. A few people who just aren't talkers come for half hour sessions.

I've worked in a number of community mental health centers. I know some clinics have huge caseloads and a full-time doc may have 500-1000 patients. I've never worked anywhere like this. Most of the clinics I've worked in have left the frequency of visits up to the doc, though certainly there is a clinic tone. In one clinic I worked in, most patients saw the doc once a month, where I work now, it's once every three months for patients who are stable. The therapist attends those sessions, and they may be quite brief....many of the patients don't seem to want to talk, and the paperwork burden imposed by the regulatory agencies are very heavy. Still, the standard at all the clinics I've worked in is 2 patients an hour. The no show rate is high, and sometimes a 3rd patient may be squeezed into the schedule if there is a scheduling problem.
My record is 15 patients in one day, and this was while I was volunteering at a clinic in Louisiana after Katrina, and the clinic had no full time doctors and a huge demand. It was 15 patients I'd never seen before, some were quite troubled, and it was a tiring day for me. So my hat goes off to those docs who see 4-6 patients an hour. I couldn't do it.

So what is the standard? I thought I'd ask. Of our readers, it looks like many see their psychiatrists weekly and many see them for 50 minute sessions. Just thought I'd ask. Thank you for taking my surveys and please do add your comments.

Unemployment Is Not Good For Your Mental Health

From the NYTimes, "Poll Reveals Trauma of Joblessness in US" by MICHAEL LUO and MEGAN THEE-BRENAN

The article notes:

With unemployment driving foreclosures nationwide, a quarter of those polled said they had either lost their home or been threatened with foreclosure or eviction for not paying their mortgage or rent. About a quarter, like Ms. Newton, have received food stamps. More than half said they had cut back on both luxuries and necessities in their spending. Seven in 10 rated their family’s financial situation as fairly bad or very bad.

But the impact on their lives was not limited to the difficulty in paying bills. Almost half said unemployment had led to more conflicts or arguments with family members and friends; 55 percent have suffered from insomnia.

“Everything gets touched,” said Colleen Klemm, 51, of North Lake, Wis., who lost her job as a manager at a landscaping company last November. “All your relationships are touched by it. You’re never your normal happy-go-lucky person. Your countenance, your self-esteem goes. You think, ‘I’m not employable.’ ”

A quarter of those who experienced anxiety or depression said they had gone to see a mental health professional. Women were significantly more likely than men to acknowledge emotional issues.

Rethinking Antidepressants

Thanks to Henry for sending this link.

On cnet news, Elizabeth Armstrong Moore writes about research presented at this month's Neuroscience conference in Chicago:

Depression researcher Eva Redei presented research at the Neuroscience 2009 conference in Chicago this week that calls into question two tenets of depression science: that stressful life events are a major cause of depression, and that an imbalance in neurotransmitters triggers depressive symptoms.

Armstrong goes on to report that the research looks at the overlap of genes in RATS (not peeps) and notes that antidepressants work better for stress then depression and the genetic overlap between the two is minimal (--oh, why isn't Roy writing this, he's so much more eloquent than I am about the genetic stuff).
Armstrong goes on to say:

To test the long-held belief that stress is a major cause of depression, Redei looked for similarities between these two sets of genes. Out of more than 30,000 genes on the microarray, 254 were related to stress and 1,275 to depression. Only 5 were found in both samples.

"This finding is clear evidence that at least in an animal model, chronic stress does not cause the same molecular changes that depression does," Redei says. She is now looking at the genes that differ in the depressed rats so that she can narrow down targets for drug development.

Antidepressants are also often ineffective, Redei says, because they aim to boost the neurotransmitters serotonin, norepinephrine, and dopamine, whose reduced levels have been associated with depression. But this strategy is now also being called into question.

It's sort of news to me that we thought stress "causes" depression. I guess I thought extreme stressors (as opposed to general 'stress') can precipitate depression in those inclined to become depressed. Many people suffer extreme distress without getting major depression and many people with histories of major depression weather severe storms without a recurrence. What is nice about this research is that it challenges us to think in new ways, and I think sometimes research gets hooked around theories that aren't definitely proven and creativity gets stifled. Anything that nudges that can't be bad....

A Session With Dr. Whippy

Artist Demitrios Kargotis has invented a soft-serve dispensing machine which uses voice-stress analysis to determine how much soft serve to give to the customer...er...client...er...patient. The more stressed out you are, the more soft serve you get.

But will insurance reimburse?