WGBH News: Medical Treatments

Fear of Antidepressants Leads People To Shun Treatment

Wed, 14 Sep 2011 15:28:00 GMT

Antidepressants are the second-most-prescribed drug in the U.S., making them seem about as common as Pez candy.

Yet many people won't tell their primary care doctor that they're suffering symptoms of depression because they're afraid they'll be prescribed antidepressants, according to some new research. And the people who are suffering the most are the ones least likely ask for help.

There's long been a stigma about mental illness, and though people are far more upfront about depression than they were in years past, that stigma hasn't gone away. Just ask someone who's been turned down for life insurance because they took antidepressants long ago, or someone who's afraid to tell the boss why they're struggling to make it in to work.

But clinical depression is common, affecting almost 7 percent of adults each year. Given that, and the suffering it causes, you'd think people would be hustling to the doctor's to get help. But you'd be wrong.

Researchers asked more than a thousand Californians if they would tell their primary care doctor about symptoms of depression. Almost half the people said they had their reasons for keeping the symptoms secret. The No. 1 reason: 23 percent said they feared that they would be prescribed antidepressants.

"There's this anxiety about medications in general," Robert Bell, lead author on the study, told Shots. With antidepressants, he said, that anxiety includes worries about side effects as well as stigma.

The findings were published this week in the Annals of Family Medicine.

There were other reasons for not telling. People didn't think that it was a primary care doctor's job to deal with emotional issues. They had fears about confidentiality. They feared being referred to a psychiatrist. And they didn't want to get tagged as a psychiatric patient. The more depressed the people were, the more likely they were to say that these reasons for not seeking care applied to them.

Bell is especially concerned about the notion that people won't seek treatment for depression from a primary care doctor, because that's where care for depression is most readily available.

"Depression is something that the primary care physician is trained to deal with," says Bell, who is a professor of communication and public health at the University of California, Davis. "I think most people assume if you're depressed that you're off to the psychiatrist, and that's not true."

A recent study found that 7 percent of all visits to a primary care doctor include a prescription for antidepressants, but other studies have found that 25 percent of people with depression aren't getting diagnosed or treated in primary care. [Copyright 2011 National Public Radio]

The 'Next Big Step': Preventing 1 Million Heart Attacks And Strokes

Tue, 13 Sep 2011 20:03:00 GMT

They're calling it Million Hearts – a newly launched campaign to put a half-dozen simple and proven public health strategies into wider practice. Federal health officials say it can prevent a million heart attacks and strokes between now and 2016.

Federal officials call it "the next big step" in cardiovascular prevention. There's lots of evidence it's an achievable goal.

First, deaths from cardiovascular disease have already been cut by 60 percent over the past generation. About half of that reduction is due to better diet, smoking cessation and other public health measures. The other half comes from from better medical treatment.

"But we still have a long way to go," Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, told Shots. "We still have 107 million adults — just about half of all adults — who either have blood pressure out of control, cholesterol out of control, or who smoke."

The campaign has two parts. One aims to change the behavior of doctors and patients. The other aims to change what all of us eat. Both are summed up by the acronym ABCS – which stands for aspirin, blood pressure control, cholesterol control and smoking.

In the realm of doctors and patients, Frieden and a phalanx of other federal officials want to expand by 10 million the number of Americans who have their high blood pressure under control and by 20 million those with controlled blood cholesterol levels.

To get there will require raising blood pressure control from less than half the people with hypertension now to 65 percent. Cholesterol control will have to triple.

The other medical-care strategy is to get people at high risk of heart attacks and strokes to take a baby aspirin every day. Fewer than half now do. The government wants to get that up to 65 percent.

Another goal is to get four million smokers to quit by 2016. That target is more modest – lowering smoking prevalence from 19 percent of adults today to 17 percent five years from now.

The smoking-cessation part of the campaign is part medical, part public health. "Less than a quarter of people who smoke get evidence-based help to quit," Frieden says.

Getting doctors to urge patients to quit "doubles the likelihood of a successful quit attempt," Frieden and Dr. Donald Berwick, the chief of Medicare and Medicaid, write in an article posted Tuesday by the New England Journal of Medicine. Prescribing one of the seven approved smoking-cessation drugs further increases quit rates.

The public health part of the stop-smoking initiative is familiar. A year from now it'll be stepped up by graphic new warnings on all cigarette packs – unless the industry gets courts to block them.

All these strategies "could save more than 100,000 lives a year," Frieden and Berwick claim. Over five years that adds up to half the Million Hearts goal.

The rest is supposed to come from two big changes in what Americans eat. Federal officials want to cut average daily salt intake by 20 percent.

But this doesn't mean throwing away the saltshaker, Frieden says. "Most Americans eat about twice as much sodium as we should get," he says. "About 80 percent of that comes in restaurant and packaged foods — it's not what you add at the table.

"What the studies show," he adds, "is that if you take half of the salt out of food and tell people 'put as much salt on as you want,' they only put back about 20 percent of what got taken out."

So the Food and Drug Administration plans to work with the food industry to cut back on the salt that's already in food when it gets on the plate. Other agencies will press for reduced salt in food the government pays for and will try to raise consumer awareness.

Similarly, the government wants to eliminate artificial trans fat in purchased foods — chemicals that raise levels of bad cholesterol and lower good cholesterol. Already, Americans' consumption of trans fat has been reduced by half; going the rest of the way could save 50,000 lives a year, according to Frieden and Berwick.

This is the public face of the campaign. Behind the scenes, one driving force of Million Hearts is the realization that with more doctors using electronic medical records and adopting new medical information technology systems, improving cardiovascular preventive care is "the best place to start," Frieden says.

"Most of us get reminders from our dentists or auto mechanics or our vet if our teeth or car or pet needs maintenance," Frieden says. "But we rarely get a reminder from our doctor."

If Million Hearts works as intended, that will change. [Copyright 2011 National Public Radio]

Calif. Medicaid Expansion: A Lifeline For Ex-Convicts

Tue, 13 Sep 2011 04:01:00 GMT

California has embarked on an ambitious expansion of its Medicaid program, three years ahead of the federal expansion that the health law requires in 2014. At least half a million people are expected to gain coverage — mostly poor adults who never qualified under the old rules because they didn't have kids at home.

Among those who stand to benefit right now are ex-offenders. Inmates often leave California prisons with no consistent place to get medical care. But that's changing.

Common Medical Problems Often Go UntreatedJust outside the metal gates of San Quentin State Prison north of San Francisco, a prison van stops and Darren Thurmond lumbers out. He wears a prison-issued gray sweat suit, stretched tightly over his large belly, and carries his possessions in a crumbled brown paper bag. A counselor from a local health clinic is here to give him a ride to Oakland.

Thurmond has been in and out of prison over the last 20 years for cocaine and methamphetamine possession. Now, at 45, all the drug use and hard living has damaged his heart. He hasn't had health insurance since he was a kid, and his heart problems were first diagnosed and brought under control in prison. But each time Thurmond gets out, he's left with a four-week supply of medication and no insurance.

"I can't afford any health care right now," Thurmond says. "Hell, I'm on parole. I'm in and out of the system. You know?"

Thurmond's first stop after his release is at a non-profit called Healthy Oakland. It's one of the few clinics in California that offers medical care to ex-convicts who have typically been excluded from public insurance programs.

Thurmond sits down for a full medical check-up with George Pearson, the clinic's physician assistant. They go over his heart problems, his weight and the painful arthritis that's overtaking Thurmond's hips.

Pearson says a 45-year-old ex-convict will often have the ailments of someone 10 years older. Ex-convicts have higher rates of almost all chronic conditions, like high blood pressure, diabetes and asthma. It's from living a hard life, to be sure, he says, but it's also because they have common medical problems that go untreated.

"So the hypertension becomes heart failure, the diabetes becomes diabetic neuropathy, amputation, blindness," Pearson says.

Bringing Order To Chaotic Lives

Now, many of those getting out of prison and other poor adults in California are being enrolled in a Medicaid-like program where they will be covered for preventive care, prescription drugs, specialty visits and mental health and substance abuse — pervasive problems that when left untreated, researchers say, can lead offenders right back to prison or jail.

Pearson says giving ex-offenders health insurance and assigning them a regular doctor brings some order to their chaotic lives.

"Their whole life is transitional," he says. "And it lacks stability. You need a facility that's going to be the home of their records, going to know them as a person. That itself prevents overutilization of the E.R. and that kind of thing. Because if he talks to me first, he may not need to go to the E.R. Or if he goes there he goes intelligently."

Some county health departments in California are using new federal money to restructure their safety nets to look more like a robust health care system.

Alex Briscoe runs Alameda County's public health department. The county is home to more than 1.5 million people, including an enormous ex-offender population, mostly in Oakland.

"Historically, services for this population are fragmented and tend to be episodic," Briscoe says. "And what we're trying to do is prepare for health reform by assigning all consumers in our system, all clients in our system, to a medical home."

That means asking ex-offenders to pick one place to get their basic medical care. Briscoe is also adding mental health therapists to county primary care clinics.

Those preparations are especially important as California begins to comply with a court order to reduce its state prison population. To relieve overcrowding, thousands of lawbreakers are expected to be put on probation in their home towns instead of going to state facilities. That means even more ex-offenders signing up for coverage, which will add an additional burden, many say, to an already maxed out Medicaid system.

Not A Cure-All

Still, providing coverage, experts say, is important for public health. Emily Wang of the Yale School of Medicine says many former inmates return home with serious mental health problems and communicable diseases.

"Treating substance abuse, HIV, hepatitis C will reduce the disease rates in our communities," she says.

Wang and others say health insurance, though, is not a magical cure for a group of people with more pressing, everyday needs.

After Darren Thurmond finished his doctor's visit at Healthy Oakland, I drove him to a pharmacy to pick up his many prescriptions — a trip that would have taken an hour by bus and a painful walk with his arthritic hips. After, we headed to a Mexican restaurant in downtown Oakland for lunch. Thurmond had fantasized in prison about authentic enchiladas.

He is thankful, he says, that he now has a regular doctor. But he's homeless, living in his van and can't quite figure out how he'll get to his appointments to get his blood work checked or his prescriptions re-filled.

"Being homeless, often I have the time to do it, but I don't have the gas to get there," he says.

For now, Thurmond is thinking pragmatically. It's his first day out of San Quentin and top on his mind is finding a job, getting money for food, necessities and gas, and finding a place to shower. With no hint of pity, he says, "I'm pretty resourceful." [Copyright 2011 KQED Public Broadcasting]

Fewer Shots Of HPV Vaccine May Still Protect Against Cancer

Thu, 08 Sep 2011 19:47:00 GMT

Women who didn't get all three doses of HPV vaccine, as is recommended, were still protected against the virus that causes cervical cancer, a new study finds. If that result holds up, it could become easier and less expensive to protect women against this common form of cancer.

Three doses of the vaccine within six months are currently recommended. In this study, which is part of ongoing research on the HPV vaccine in Costa Rica, about 20 percent of the women didn't get all three shots because they got pregnant or had other medical issues. Half the women in the study were randomly assigned to receive Cerverix, an HPV vaccine from GlaxoSmithKline, or a vaccine against hepatitis A.

When women who had gotten one or two shots of Cerverix were tested for HPV infection, they were just as well protected after four years as women who received the full regimen.

The United States added the HPV vaccine to recommended vaccinations for teenage girls in 2006. But only about 32 percent of 13- to 17-year-old girls have gotten all three shots.

The three-shot series is inconvenient, since girls need to make three trips to the doctor's office for the full series. And it's expensive — about $400. So if two shots, or even one shot, would do, vaccination would be simpler and cheaper. That's particularly true for women in developing countries, who often don't have access to frequent screening checkups such as Pap smears.

But this study has followed the young women who are participating for just four years so far, and women need to be protected from their teens up into their 20s, according to Aimee Kreimer, an investigator at the National Cancer Institute, and lead author on the study. "We need to protect them during the main time of sexual activity," she told Shots. "There's a concern that the duration of the protection for fewer than three doses will not be as long."

The study, which was published in the Journal of the National Cancer Institute, will follow the 7,153 women in the study for another six years, Kreimer says. "But really, 15 years would be ideal." That would give young women and their doctors a much clearer sense of whether three doses are really needed for protection. [Copyright 2011 National Public Radio]

Medical Mystery Of Chronic Fatigue Syndrome Returns

Mon, 05 Sep 2011 09:59:00 GMT

Probiotic Bacteria Chill Out Anxious Mice

Fri, 02 Sep 2011 17:00:00 GMT

Delivering Viruses To Try And Kill Tumors

Fri, 02 Sep 2011 17:00:00 GMT

FDA Chides Pfizer For Omitting Drug Risks On Lipitor Website

Fri, 02 Sep 2011 16:00:00 GMT

Somebody who didn't like the way Pfizer was promoting a bunch of its drugs on a website for cholesterol-fighter Lipitor tipped off the Food and Drug Administration about it. And the agency agreed.

In a written reprimand, the agency faulted Pfizer for failing to tell people about risks from Caduet, a pill to treat high cholesterol and blood pressure; Norvasc, for high blood pressure; and Chantix, a pill to help people quit smoking.

The basic problem, according to the FDA, was that links to pages with more information about these drugs featured language describing what the piils do without mentioning any of the risks they pose.

"By omitting the most serious and frequently occurring risks associated with Caduet, Chantix, and Norvasc, the webpage misleadingly suggests that these drugs are safer than have been demonstrated," the FDA wrote.

Pfizer has until Sept. 14 to respond to the agency's letter. In an email to Shots, a Pfizer spokesman said the company "is in the process of reviewing and responding to the FDA letter and has already removed the cited content from the Lipitor website."

The Pfizer letter is just the latest FDA enforcement action spawned by a "bad ads" initiative launched in May 2010. FDA Commissioner Margert Hamburg asked doctors, nurses and pharmacists around the country to become tipster and help root out false and misleading marketing of drugs.

In a report on how things are going, the agency said in the first year it received 328 tips, more than triple the yearly average before the call for help. Most came from health professionals, and 87 of those prompted a careful look by the FDA. For a look at some of the problems that resulted in action, you can find links to five agency letters here.

For all the hoopla, most doctors remain unaware of the tip program, according to a survey highlighted by the blog Pharmalot in March. Speaking of, I was unaware of the latest action against Pfizer until Pharmalot blogged about it this morning.

For more on how the tip program is supposed to work, check out the FDA video. [Copyright 2011 National Public Radio]

Efforts To Track Long-Term Safety Of Silicone Breast Implants Flounder

Thu, 01 Sep 2011 19:07:00 GMT

Silicone breast implants can cause problems for women who have them, and many have to have surgery to remove or replace the devices within 10 years. But implant manufacturers have done such a poor job of tracking problems that a Food and Drug Administration advisory panel says it may be time for a nationwide database of women with implants.

The FDA had required the two manufacturers of silicone breast implants, Mentor Worldwide LLC and Allergan Inc., to conduct 10-year-long studies on side effects as a condition of allowing the implants back on the market in 2006. After two years, about 60 percent of Allergan patients were still participating, but just 21 percent of Mentor patients were involved. The studies were supposed to follow 80,000 women.

The concern is that with so few women participating, there won't be enough data to really know if silicone implants pose long-term health and safety problems.

People who testified at an FDA hearing this week said women may have dropped out of the study because the 27-page forms women were expected to fill out were too burdensome. Or it could be because Mentor paid women and doctors small amounts of money to participate, while Allergan did not. The two-day hearing was held in Gaithersburg, Md.

Consumer advocates say that the manufacturers' problems in tracking side effects like scarring and leakage shows that the FDA doesn't provide enough oversight of medical devices, which run from cosmetic implants to pacemakers and hip joint replacements.

"This is one of the most visible, controversial medical devices, and they can't even get the data right," Diana Zuckerman, president of the National Research Center for Women & Families, told Shots. "If this is what they're doing with the controversial, visible ones, what's happening to the ones we're not paying attention to?"

In July, the independent Institute of Medicine found that the FDA's system for overseeing the safety of medical devices was so flawed that it should be scrapped rather than retooled.

Several advisory panel members said the FDA's requirement that women have frequent MRIs to make sure the implants haven't ruptured is unrealistic and should be removed from the product label. Insurance usually doesn't pay for the scans, so most women don't get them done. But it's the only way to find out whether the implant has ruptured in the absence of symptoms.

Earlier research had found that 20 to 40 percent of women receiving implants for cosmetic reasons, and 40 to 70 percent of women who received implants for reconstruction, had to have another operation to remove or replace them within 10 years of getting implants.

FDA officials said silicone implants will stay on the market while they work with manufacturers and consumer groups to come up with ways to boost participation in the studies.

"FDA continues to believe currently approved devices are safe and effective," said William Maisel, deputy director of the device division for FDA. However, he added, "There is a significant complication rate." In June, the agency had reviewed the data from the manufacturers' studies, and termed the implants "generally safe." [Copyright 2011 National Public Radio]

At Walter Reed, Military Medicine Fights Malaria

Thu, 01 Sep 2011 16:56:00 GMT

Part of our series on the closure of the Walter Reed Army Medical Center.

Army Maj. Jittawadee Murphy peers into a paper bucket full of freshly hatched Anopheles stephanii mosquitoes. She needs to separate out the females — the only ones that bite — so they can be infected with malaria.

It turns out that sexing mosquitoes is easy.

"We kind of trick them," says Murphy, an entomologist. Female mosquitoes gravitate to any heat source, thinking it might be their next warm-blooded dinner wagon. So Murphy places the bucket next to a hot plate. "That side of the bucket is hot now," she says. "So all of the gals – the female mosquitoes – go and sit on that side of the bucket."

And once the females make their move, Murphy can suck them up through a straw.

These insects will be presented with some malaria-infected human blood to feast on. And then they'll be allowed to suck the blood of human volunteers --incidentally injecting them with Plasmodium falciperum, the deadliest kind of malaria.

It sounds bizarre, and even unethical. But in fact, over decades this kind of human experiment at the Walter Reed Army Institute of Research has produced an unparalleled outpouring of drugs and vaccines to prevent and treat malaria, one of the world's leading disease threats. It kills nearly 800,000 people every year — most of them infants, children and pregnant women in sub-Saharan Africa.

Human Experiments — And Success

Deadly as it potentially is, it's not unethical to infect human research subjects with falciperum malaria, because the infection is entirely curable — as long as it's treated within 36 hours after symptoms appear.

After 36 hours, the level of malaria parasites in the blood gets so high that "it becomes a race between how fast the parasites can be killed with medication versus how fast they're multiplying in the blood," says Col. Christian Ockenhouse, who's in charge of developing malaria vaccines at the Walter Reed Institute.

None of the 1,000 volunteers infected in Walter Reed experiments has died or suffered lasting damage from the experiment, Ockenhouse says.

Most people know "the Walter Reed" as a mammoth military medical center in Washington, D.C., where both U.S. presidents and ordinary war-wounded soldiers get their care.

But as the Walter Reed Army Medical Center decamps from its D.C. campus this month and merges with the Bethesda Naval Hospital five miles away, it's a good time to look at the wider Walter Reed legacy.

The center's Walter Reed Army Institute of Research, housed for the past decade on its own campus in Maryland, just outside Washington, is one of the world's premier research centers for infectious diseases.

No other place has done as much to prevent and treat malaria. And certainly, no one has done it so cheaply.

Ockenhouse says the Defense Department spends only $15 million a year on malaria research — $10 million on drug development and $5 million on vaccines. That's a mosquito-sized portion of the DOD's $680 billion budget.

Malaria: A Millennia-Old Foe For Soldiers

Malaria has always been a problem for soldiers. Roman legions had to contend with it. So did George Washington's troops. Civil War battles were won and lost because of it. And it was a huge problem in the South Pacific during World War II.

Professor Dale Smith, a military medical historian at the Uniformed Services University of the Health Sciences, recounts a famous complaint that Gen. Douglas MacArthur made to Dr. Paul Russell, then the Army's top malaria expert.

"Doctor," Smith quotes MacArthur as saying, "it's going to be a very long war if for every division I have facing the enemy, I have one sick in hospital and another recovering from this dreadful disease."

MacArthur wasn't exaggerating. Smith says the U.S. military counted more than a half-million cases of malaria during World War II. "Malaria is a troop-waster," Smith says.

During the war, the Japanese controlled the world's supply of quinine — the standard anti-malaria drug at the time, most of which came from Japanese-occupied Indonesia. So the Americans muddled through with a drug called Atabrine. But it wasn't a great drug. It famously turned soldiers' skin and eyes yellow, had other nasty side effects — and was (incorrectly) rumored to cause impotence.

So, Walter Reed scientists launched a successful effort to find new malaria drugs. At the time, it was the largest campaign ever launched to find new drugs.

"The whole first generation of malaria drugs came from that war effort," says Dr. Alan Magill, a retired Army colonel and malaria expert.

Then, the war ended. And so did the U.S. military's interest in malaria.

"By early 1946, the entire malaria drug development program was discontinued," Magill says. "People went home, they went back to their jobs. And like someone turned a light switch, that program ended."

Malaria was a bit of a problem in Korea. But it came roaring back as a major military headache in the Vietnam era.

In the first big clash between U.S. and North Vietnamese forces, the battle of Ia Drang Valley in 1965, malaria was almost as big an adversary to both sides as the enemy's soldiers.

By then, Army medics had a drug called chloroquine that had been introduced in 1947, a result of the wartime program. (U.S. researchers were lucky enough to stumble upon the Germans' recipe for chloroquine among the records left behind when the Americans liberated Tunisia.)

But Magill says that by the mid-1960s, malaria parasites in Southeast Asia had grown resistant to chloroquine.

"It was a devastating time," he says. "We literally introduced a half-million non-immune Americans into Vietnam facing chloroquine-resistant falciperum malaria. And of course, all we had was chloroquine."

Walter Reed scientists came to the rescue. Another crash campaign produced a whole slew of new anti-malaria drugs — something drug companies weren't eager to do, because the disease just wasn't important in the developed world.

An Adapting, And Complex, Adversary

Malaria drug development is no less important today, because the malaria parasite has developed resistance against every new drug scientists have thrown at it.

And now, malaria in Southeast Asia is developing resistance to the current final bastion against the parasite, a class of drugs called artemisinins, which come from a Chinese herb.

Alan Magill says that's alarming. "If we were to lose that class of drugs, we don't have an obvious candidate for a backup," he says.

That possibility has increased the urgency to develop the ultimate weapon against malaria: an effective vaccine.

Many have said it would never be possible. Malaria parasites are by far the most complicated organisms that anybody has ever tried to vaccinate against. They're far more complex than viruses or bacteria.

But back in the 1980s, Walter Reed researchers produced the first glimmer that a vaccine against malaria could work.

That launched several years of dogged research that continues today, with the help of volunteers willing to risk getting malaria to test each new experimental vaccine.

A Test Subject's Perspective

Army Spc. Navdeep Saini is one of the human guinea pigs involved in the new research.

"I'm originally from India – northern India, it's called Punjab," he says. "I've seen a lot of people suffering, having this malaria. And I've seen a lot of kids dying from this disease. So that was a big motivator to participate — to help science get these vaccines out, and help those people back home."

Once again, the research has paid off. A vaccine that came out of Walter Reed is now in the final stages of a human trial involving nearly 16,000 children throughout sub-Saharan Africa. It's the first malaria vaccine ever to reach this advanced stage.

Results are expected later this year. In earlier smaller trials, the vaccine was 40 to 50 percent effective in preventing malaria. That's good enough to save millions of lives.

In combination with anti-malarial drugs, insecticide-treated bed nets and mosquito control, even a partially effective vaccine might get the world over the hump toward the ultimate victory of eradicating malaria.

But Col. Ockenhouse, who leads the Walter Reed Institute's malaria vaccine program, says a 50 percent effective vaccine isn't good enough for the military.

"The U.S. military requires an 80 percent effective vaccine – at least 80 percent," Ockenhouse says. "Because to lose even 10 percent of individuals to the mission is really unacceptable."

So, the day after we visited the Walter Reed Institute's "insectary," as the insect factory is called, Ockenhouse began a trial of a new, tweaked version of the vaccine. "We'll know in a year if it works," he says. [Copyright 2011 National Public Radio]