EMOTIONAL STATUS AND SURVIVAL: WHAT DO WE KNOW?

 

emotions

All of us have heard the expression, “I am worried to death!” But is this merely a figure of speech, or is there any literal truth to such a statement? So let’s take a look at what science has to offer:

Multiple studies have shown that people who are lonely and depressed are over three times more likely to get sick and die prematurely—in contrast to people who are not depressed, and especially those who have a stronger sense of love, connection, and community. For example, one report disclosed that 6 months after a heart attack, people who were depressed were four times more likely to die than those who weren’t depressed. This was independent of the usual risk factors like cholesterol, blood pressure, weight, and even smoking. Consistent with that observation, there have been hundreds of studies showing that people who are lonely and depressed are many times more likely to get sick and die prematurely—from all causes as well as heart disease—when compared with those who have a strong sense of love, connection, and community. Such observations are consistent with studies that have shown that being married—at least happily—are actually good for your heart. In one recent survey out of New York University’s Lagone Medical Center, researchers found that married men and women had a five percent lower chance of cardiovascular disease compared to single people. We aren’t entirely sure why, but it’s possible that since marriages typically offer a person emotional support, physical and intellectual intimacy, as well as deeper social ties to family, they might improve overall health.  Consistent with this concept, one study found that people in a bad marriage were actually more likely to experience negative cardiovascular effects, compared to people in good marriages. Thus it’s not necessarily about whether you’re married or not, it’s all about how happy it’s making you.

This raises the question of whether the adverse outcomes are due to the emotional disruption or to the poor lifestyle choices made by those who are depressed or nervous. It is true that some people who are lonely and distraught are more likely to do things that are self-destructive, for example, smoke excessively or fail to take medicines as prescribed. But these explanations seem to fall short of the real truth, as explained below.

There are ways that mental health issues can directly affect heart disease, as reflected in the growing belief that depression and anxiety are risk factors that are even more dangerous than others such as diet. Stress can increase hormones like adrenaline and cortisol, and can impact one’s blood pressure and heart rate in an unfavorable way. Moreover, people with depression have been found to have uncommonly sticky platelets, the tiny cells that cause blood to clot. In patients with heart disease, this can accelerate atherosclerosis (hardening of the arteries) and increase the chance of heart attack. Some studies suggest that treating depression makes platelets less sticky again.

Even animal studies have demonstrated that positive emotional support can foster better health. One study dealt with atherosclerotic rabbits.  Rabbits were put on a high-cholesterol diet with the assumption that they would all get heart disease. The rabbits were stacked in cages up to the ceiling, and the ones up high got heart disease a lot more than the ones in the lower cages, which made no sense. What they found was that the lab technician, who was short, would come in to feed the rabbits and would play with the ones in the lower cages because she could reach them, and she would ignore the ones in the higher cages. The study was repeated with genetically comparable rabbits fed the same diet, and they randomly divided the rabbits into two groups. With one group they would take the rabbits out of the cages, play with them, and love them They found that the rabbits that were touched, talked to, petted, and played with had 60% less atherosclerosis than those that were ignored, even though their serum cholesterol levels, heart rate, and blood pressure were comparable.

Similar findings have been reported with male monkeys, for those that were stressed had significantly more extensive coronary artery atherosclerosis compared with a control group of monkeys that weren’t stressed, even though their cholesterol, blood pressure, blood sugar, weight, etc. were not different.

In medicine, we focus on what we can see and measure easily. We can measure cholesterol and blood pressure easily so we tend to focus on those things. The American Heart Association still doesn’t list emotional stress in their seven key modifiable risk factors. There is a saying that not everything that counts can be counted. In other words, not everything that is meaningful is measurable. We tend to focus on what is easily measurable, even though these psychosocial factors are probably as important—and in some ways, even more so.  Scientists are getting more innovative at measuring these factors. In a recent study, researchers analyzed 148 million Twitter messages (tweets) across the United States and found that language patterns reflecting negative social relationships, disengagement, and negative emotions—especially anger—were risk factors for heart disease at a county level and were even more predictive than smoking, diabetes, hypertension, and obesity. In contrast, positive emotions and psychological engagement were protective.

Maintaining a positive attitude about treatment and holding the belief that our actions can have a beneficial effect on our own health are very important. A person’s attitude seems to have a powerfully favorable effect on their ability to make behavior and lifestyle changes that are often necessary to reduce the risk of having future health problems. A person’s attitude also influences the response to treatment.

So what can we do about these emotional problems, and can countermeasures alter one’s odds of survival?

Although treatments such as psychotherapy and drugs are often used to improve emotional status, the results of such measures are complicated and difficult to measure, leaving us in doubt about their individual effects on survival. Regular exercise, however, has been proven to reduce both depression and risk of disease. Various studies have shown that participation in exercise training programs was comparable to treatment with an antidepressant medication (a selective serotonin reuptake inhibitor) for improving depressive symptoms in older adults diagnosed with major depression.  Exercise per se also offers significant protection against heart disease and many cancers as well.  Included among the many benefits of regular exercise is the lessening of the likelihood of upper respiratory infections and reduction of the severity of symptoms if you do get one. The reason for this protection is unclear, but exercise’s demonstrated reduction of inflammation and its boosting of general immunity in the body may play a role.

Conclusion

Although it’s difficult to separate and determine the effects of pure emotional support on survival, it is highly likely that such countermeasures are effective. Regardless, however, combating depression and anxiety and promoting more social interaction that include love and respect are beneficial goals in themselves, making for a happier and healthier individual, and hopefully, a longer life as well!

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THE “DEATH” OF THE DEATH PENALTY?

      executions

For a host of legal and political reasons as well as the scarcity of lethal drugs for injection, the number of executions has declined in the U.S. to just 28 in 2015, compared with a recent peak of 98 in 1999. Because of difficulties in obtaining lethal drugs, some states have approved alternative means such as firing squad or gas chamber as more “delectable” means of dispatching wrongdoers. Methods by state are summarized below:

  • Electrocution in Florida, Oklahoma and Tennessee.
  • Gas inhalation in California, Missouri, Oklahoma and Wyoming.
  • Hanging in Delaware and New Hampshire.
  • Firing squad in Oklahoma and Utah.

But this controversy invites the larger question of whether there is any overall justification for this, the severest, of penalties. (Full disclosure here: I am firmly opposed to the death penalty under any circumstance, which is in agreement with a total ban by most civilized western societies!)

Although my reasons for opposition to executions are complex, they can be boiled down to a few simple principles: 1) Some condemned persons are, by virtue of later evidence, proven innocent, 2) It is impossible to apply equal justice to many disadvantaged individuals representing minorities or the poor 3) No credible scientific studies have ever shown that capital crimes can be reduced by this threatened means, 4) It is not only more humane, but also less expensive to levy life sentences in preference to forcing inmates to sit endlessly in death rows while progressing through a seemingly endless sequence of appeals.

As a physician, I have always been committed to preventing both death and suffering, and in this capacity, have tried to avoid either of these events as much as possible. As I explained in a previous post: http://www.mortontavel.com/2016/05/01/. However, in the case of extreme suffering, I believe that physician assisted suicide is acceptable when patients request it, are of sound mind, and no better alternatives to sparing life are available.

By contrast, I do not believe that physician assisted murder (AKA execution) is ever permissible, and that is why most of my fellow physicians are unwilling to participate in such a repugnant and gruesome spectacle. So by default, the actual practice of execution by lethal injection often is relegated to medical surrogates who are less well trained and more apt to botch these procedures, especially when they are supplied with inferior or unproven drugs.  Adding to this problem, corrections officials often conceal how drugs are obtained, and, therefore, lawyers for condemned inmates have challenged these efforts to mask this information, saying this makes it impossible to know if drug concoctions meet quality standards or might cause undue suffering. “States are shrouding in secrecy aspects of what should be the most transparent government activity,” said Ty Alper, associate director of the death penalty clinic at the University of California, Berkeley, School of Law

Before Missouri put to death a prisoner recently, for example, it refused to say in court whether the lethal barbiturate it used, pentobarbital, was produced by a compounding pharmacy or a licensed manufacturer. A majority of the 32 states with the death penalty have imposed secrecy around their drug sources, saying that suppliers would face severe reprisals or even violence from death penalty opponents. In a recent court hearing, a Texas official argued that disclosing the identity of its pentobarbital source “creates a substantial threat of physical harm.”

Recently, the giant pharmaceutical company Phizer decided against provision of drugs for executions. This move followed its acquisition last year of Hospira, a company that has made seven drugs, including barbiturates, used in executions, a combination of agents that cause paralysis and heart failure. Hospira had long tried to prevent diversion of its products to state prisons but had not succeeded; and its products were used in a prolonged, apparently agonizing execution in Ohio in 2014. They are stockpiled by Arkansas, according to documents obtained by reporters. Because these drugs are also distributed for normal medical use, there is no way to determine which of the agents used in recent executions were produced by Hospira or Pfizer.

Campaigns against the death penalty, and Europe’s strong prohibitions on the export of execution drugs, have raised the stakes for pharmaceutical companies, and many, including Pfizer, say ethical concerns have also guided their policies. “Pfizer makes its products to enhance and save the lives of the patients we serve,” the company said in Friday’s statement, and “strongly objects to the use of its products as lethal injections for capital punishment.” Pfizer said it would restrict the sale to selected wholesalers of seven products that could be used in executions. The distributors must certify that they will not resell the drugs to corrections departments and will be closely monitored.

Despite all this controversy, however, it seems probable that the Supreme Court will soon have the final word, and given its likely makeup coming soon, we may see the end of the barbaric death penalty for all future generations, which is a positive step for this nation, if not for all humanity! And to that I would say let’s allow this penalty to suffer a natural death, in contrast to the many deaths that are ended unnaturally!

For further information about this issue, especially costs to the taxpayer, please visit the following website: https://www.sheilakennedy.net/2011/03/death-and-taxes-2/

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A Donald Trump Pyramid (Ponzi?) Scheme: Now Including “Snake Oil”

trump

In 2009, Donald Trump started The Trump Network as a multi-level marketing (MLM) company to sell nutritional supplements and weight loss products in addition to home business marketing packages designed to recruit affiliates and earn commissions off their sales. The business was essentially rebranded by purchasing Ideal Health, Inc., a Massachusetts-based company that already sold health products through a vast pyramid structure.

The most effective way to profit as a member of The Trump Network was not to sell individual products, but to get others to sign up as members to sell more products and recruit more members. One could make lots of money by not selling any material products, but only by recruiting sellers and earning commissions off their sales.

The Federal Trade Commission has come down hard on pyramid schemes, but has run into trouble with ones that actually sell products within a pyramid-referral structure. There are differences between an MLM company and a pyramid scheme, but the distinction can be subtle and seems to depend on the proportion of revenue that comes from recruitment versus real product sales. The Trump Network, however, appears far less of a MLM and more of a pyramid scheme.

Let’s take a look at how the Trump Network concept was advertised. On the former Trump Network website in 2009, there was a letter posted by Donald Trump himself who pitches economic opportunity for families who were suffering financially from the Great Recession:

     At no time in recent history has our economy been in the state that it is today. The economic meltdown created by Wall Street greed, financial industry ineptitude and the mortgage crisis has hijacked the dreams of millions of people. We need a new plan to achieve financial independence. My experience in real estate has taught me that the greatest opportunities emerge when economic times are at their worst. That’s why, after the real estate crash of the 90’s, I came back stronger than ever. The first thing I learned is that when times are tough you need to hedge your bets. You need to diversify. The good news is: The Trump Network can provide you with a solution to help you and your family create a more secure future. Diversifying is a way to protect your income so that you can continue to do what you know and love, and still make money. The second thing I learned is that the economy goes in cycles. When some industries fail, others take off. For example, when the real estate industry was challenged in the early 90’s, the network marketing industry exploded. During hard times, people with an entrepreneurial spirit flock to network marketing opportunities. That’s why I have put my name and expertise into supporting this opportunity. The team at The Trump Network have phenomenal products, provide easy to follow training and have a great support network available to all their members. The Trump Network offers you a financial solution that you can believe in. The Trump Network offers products that help make people healthier, an opportunity for you to make as much money as you want, based on your own efforts, and the support of a great company. Join me in this worthwhile endeavor.

     Thus Trump pitched directly to suffering families by casting the venture in terms of success, money, and security. Potential customers are told to join him and prosper by selling health products through “network marketing,” which is a less loaded term than “pyramid scheme.” Although it may sound great to an economically desperate family member, a pyramid scheme cannot offer success to everyone in the affiliate network. The people at the top always win, and those at the bottom always lose.  To compound matters further, in this instance one is actually peddling junk, as explained below.

What was Trump Selling?

The company’s flagship product was called the PrivaTest, which supposedly relies upon a mail-in urine test to determine one’s individual nutritional needs and create a custom vitamin formula (about $140 for the test; $70 per month for the vitamins; $100 to retest every 6 months). From a scientific viewpoint, urine tests do not provide a legitimate basis for recommending that people take dietary supplements. Moreover, even if they could, the nutrients in the so-called customized formulas can be obtained far more inexpensively in retail stores. The Trump Network also acquired a weight loss program called The Silhouette Solution, which consisted of a book promising to lose the weight you want and have the silhouette you choose, which was included in the starter weight loss kit, all for a whopping $1,325. The package was marketed as “a complete eight-week program that contains everything you need to achieve your short and long term weight loss goals.” In it, they send you eight weeks worth of low-calorie food.

I could provide solid information on why this approach won’t provide benefit, especially in the long run, but as the skeptical nutritionist Janet Helm put it in 2009: “This [fake-food fad diet] is not only expensive, but an approach I certainly can’t support.”

But one more payoff: To make money in addition to losing weight, one could purchase the $400 business kit to market the product to their friends and family, or even be entrepreneurial enough to hold community seminars or purchase television ads to recruit more sellers.

Interestingly, Donald Trump’s foray into this sordid world of dietary supplements and weight loss products ended in 2012 when he sold The Trump Network to Bioceutica, LLC. Trump appears to have been concerned about the liability of being associated with a MLM (a.k.a. pyramid scheme) selling bogus products. As far as we know, however, Bioceutica is still operating and continues to sell the PrivaTest and the Silhouette Solution.

In 2016, the Washington Post reported that Trump claims that his involvement with Ideal Health merely allowed them to use his name for marketing purposes and that he was not involved in the company’s operations. But the paper noted that “statements by him and other company representatives—as well as a plethora of marketing materials circulating online—often gave the impression of a partnership that was certain to lift thousands of people into prosperity.”

In light of this illustrative example (and many others), if Donald Trump becomes president, the American people can continue to count on a lot of hyperbolic talk with very little intelligent leadership. There’s always money to be made selling snake-oil, maybe even to the entire world. Thus as the old cliché goes: Buyer Beware!

 

 

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SHOULD WE SANCTION “AID IN DYING”?

Dying As a physician, I originally supported the dictum that death should be prevented at all costs. But more recently, I have come to realize that perhaps we should also more seriously consider suffering as well as dying.

These thoughts have directed my attention to the so-called “aid in dying” laws that are in force in the U.S. states of Oregon, Washington, Montana, Vermont, and California. They are sometimes referred to as “Physician-Assisted Suicide”. These examples often require that a patient’s death be expected within six months, and they compassionately offer a voluntary, self administered end to suffering at an individual’s own preferred time. Since 2014, aid-in-dying bills have been introduced in Washington, D.C. and several states. Canada is also considering such a bill. Other countries, including Switzerland and Belgium, allow aid in dying for people who are not even terminally ill.  All these laws provide freedom for a physician to prescribe a lethal drug to a patient for self administration. At present, such a practice is unlawful in 46 states..

In the example of Oregon, which has had such a law in effect since 1997, subsequent study has uncovered no abuses, and, interestingly, about a third of patients who receive medication to end their lives never actually use it, meaning that many are likely reassured by the simple knowledge that they will be able to end their lives at any time of their choosing.

Although such laws are humane and sensible, they can be abused and result in wrongful deaths. We physicians commonly encounter severely depressed patients without life-threatening physical maladies who, on their own, might opt to commit suicide. In such instances, many can be encouraged to receive effective psychiatric care, and they can be restored to happy and productive lives. Obviously, in such cases a caregiver’s assistance in suicide would represent a serious disservice. Moreover, some individuals suffering from emotional illnesses that result in painful sensations can also be deterred from suicidal acts, receive proper medical treatment, and often enjoy a happy outcome.

Laws addressing such issues should be clearly defined. First, I believe a specific time for life expectancy need not be spelled out, for misery without hope doesn’t necessarily conform to a distinct number of days or months. For instance, someone suffering from a severe progressive neurologic disease such as Lou Gehrig’s disease (ALS) can continue suffering for many months prior to death. On a personal level, I witnessed the suffering and death of a patient/friend of mine from a similar neurologic disorder called progressive supranuclear palsy (PSP), a disease that also claimed the life of actor Dudley Moore, which is an uncommon progressive fatal brain disorder that affects movement, control of walking (gait), balance, speech, and many others. Given the choice, and if it were legal, my friend would have gladly opted to end his life by assisted suicide. Even various terminal cancers can behave for variable durations, and can also cause prolonged pain and suffering.

Using the successful example of Oregon, let’s examine its basic requirements: First, the patient must make two oral requests to the attending physician, separated by at least 15 days, accompanied by a written request, signed in the presence of two witnesses, at least one of whom is not related to the patient. The attending physician and a consulting physician must confirm the patient’s diagnosis and prognosis and determine whether the patient is capable of making and communicating health care decisions for him/herself.  If either physician believes the patient’s judgment is impaired by a psychiatric or psychological disorder (such as depression), the patient must be referred for a psychological examination. The attending physician must inform the patient of feasible alternatives to the act, including comfort care, hospice care, and pain control. The attending physician must request, but may not require, the patient to notify their next-of-kin of the prescription request. The attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate.

In most cases, the drug used for this purpose belongs to a group of so-called “barbiturates”, commonly used in lower doses for the induction of normal sleep. In large doses, however, death is painless, peaceful, and will occur within a matter of minutes to hours.

A death in this fashion is often far better than other, less desirable, alternatives. Thus I might conclude with a simple question: Isn’t it more humane to deal with one’s own species in a manner at least as appropriate as the smooth and painless exit we provide to our beloved animal pets?

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