By HANS DUVEFELT, MD (7)

The other day I saw a new patient who used to be on Lamictal, a mood stabilizer. The young man explained that he had gone through a difficult time in his life a few years ago and his primary care doctor put him on Prozac, which, as he put it “hijacked” his brain and made him “ugly, hyper and careless”. The man immediately stopped the Prozac and his doctor prescribed Lamictal, which he stayed with for about a year.

He decided to stop the new medication, because he reasoned that he didn’t have any psychiatric issues. It was just a side effect of the Prozac, which he in retrospect probable hadn’t needed at all.

Since then, he admitted, he had felt sad or unsettled in the spring and fall, but it always passed and he didn’t think his wife or anybody else noticed his seasonal mood changes.

“So, did anybody actually use the word “bipolar” in talking about what you went through?” I asked.

He winced and almost seemed teary eyed. “Yeah, but I don’t think that’s right. How can you put a label on somebody that will follow them for the rest of their life because of what their brain did when, basically and literally, they were on drugs?”

I nodded.

“Who knows how many people might react the same way if you give them Prozac”, he continued.

“I think labels can hurt sometimes, but they can also be a way of understanding how our minds and bodies work”, I began. “I don’t believe diagnoses are as cut in stone as some people like to think.”

He looked quizzical as I continued:

“Take diabetes – this country and Canada have slightly different cutoffs for what a normal blood sugar is. Or blood pressure – every few years the experts pick a different number for what’s good enough and what’s  ideal. I believe most things we call diseases are points at the extremes of a spectrum that we all fall somewhere on.”

Now he was the one nodding.

“Take mood”, I continued. “At one end of the mood spectrum there is depression and at the other there is what we call mania. Sometimes that looks like exaggerated happiness and confidence, but sometimes it is more like irritability and agitation. We can all experience any one of those moods, but usually we are somewhere in the middle. So, people are making up disease definitions depending on how far and  for how long we deviate from the middle. But if we never move an inch from neutral, that’s not necessarily being healthy – I think of that as definitely abnormal.”

“I see what you mean”, he nodded again.

“As a clinician, I think of labels as a type of shorthand or mental image that I keep in mind when I approach a problem. They help me choose treatments and they help me explain things. But I tend to be slow in sticking labels on patients or in their medical records. I read a book once called ‘Shadow Syndromes’ that makes the point that looking at the extremes of whatever spectrum we are on helps us understand ourselves and can be very empowering.”

“So, Doc, do you think I’m bipolar?” He leaned forward.

“You have the tendencies, yes, but a condition isn’t a problem until someone sees it as a problem. If neither you nor the people around you see your mood variability, not to use the stronger word ‘mood swings’ as a problem, then fine. But I, knowing what you’ve told me about how your brain works, would be a fool to prescribe Zoloft or Lexapro if you ever came to me feeling terribly depressed. I would then think of you as somewhere on the bipolar spectrum, needing a slightly different treatment approach if we wanted to lift your mood.”

“A mood stabilizer, like Lamictal”, I finsished, “can be like an insurance policy against ever having a manic episode in the future, and we usually recommend long term treatment if a person has had an episode out of the blue. But I’m not so sure it’s necessary if the episode was triggered by Prozac or any other antidepressant. I’m sure there are lots of opinions about that, but that’s what I think, especially since your episode was not severe from what you’ve told me.”

On my drive home that afternoon, I thought of the spectra I may have moved along during my lifetime. I remember my mother commenting on how I had turned into such a slob; “When you were little you were so neat, you used to line everybody’s shoes up in the entryway.”

That’s the OCD spectrum, and I guess I narrowly escaped that diagnosis…

Hans Duvefelt, MD is a primary care physician based in Maine. He blogs at a Country Doctor Writes. This post is exclusive to the Deductible. His first book “” is available from Amazon.com

By DANIEL STONE, MD (3)

President Trump’s wobbly walk down a ramp at his recent West Point visit along with his awkward  two-handed drink from a water glass have stirred recent speculation about a possible undisclosed neurologic issue such as early Parkinson’s Disease.  Although no specific conclusions can be drawn from these observations, they raise important questions regarding the President’s health.    

Trump would not be the first president to conceal health problems.  Toward the end of Franklin Roosevelt’s presidency, his blood pressure rose alarmingly.  As no drug treatments existed his doctors could recommend only that he stop smoking, lose weight and avoid dietary salt.  Less than six months after an un-knowing public re-elected him to a record fourth term, FDR predictably suffered a fatal stroke.  The public was similarly unaware of John Kennedy’s Addison’s Disease, a condition that required daily injections to replace the adrenal hormones his body could not make. 

The known facts about Trump’s health are concerning enough.   Despite taking a statin drug to reduce his cholesterol, Mr. Trump’s age and risk factors at his 2018 physical predicted a 16.7%  risk of a heart attack over ten years, as estimated by a standard American College of Cardiology risk calculator.  Trump was taking a statin at the time of that exam to lower his cholesterol.  As cholesterol levels on a statin may not reflect risk as accurately as un-treated levels, the calculator may under-estimate his true risk.     Although Trump’s doctors tout his health they seemed to be concerned about cardiovascular risk as they subsequently quadrupled his statin dosage, placing him highest dose of the most potent statin available.    In addition, the President’s annual exam revealed that his weight recently drifted up into the obese range, which means additional coronary disease risk along with an increased chance of stroke, chronic kidney disease, diabetes and several types of cancers.  

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By JEFF GOLDSMITH  

The halting and uncertain response to COVID in the US is a tragic civic embarrassment.    While other countries have snuffed out the Covid-19 virus, the US seems to be grinding on toward 200 thousand deaths despite flinging trillions of dollars at the problem.  As summer approaches, the US shows every sign of declaring victory long before the foe has left the field.  Americans may be losing interest in COVID but COVID has not lost interest in us.  

What happened?   Several trillion in lost economic output, massive dislocation of American families and disgraceful disparities in health risks based on race and socioeconomic level all point to a breakdown in a key civic function. No readily deployable testing capability, critical shortages of protective gear, unappreciated and unresolved conflicts between federal and state health authorities, and critical failures in our core federal public health agency, the Centers for Disease Control and Prevention all played a role.  In retrospect, it is clear that US public health effort- $93 billion in spending in 2018, or 2.4% of total health spending, for a population of 327 million people- was grossly inadequate for the magnitude of societal risk. We spend nearly eight times as much on the military.   

Successful public health requires social solidarity and trust both in science and in government.  All are in short supply.  Early statements from political leaders about how this is no worse than the common cold or the flu and was going to “just go away”,  and the fact that the initial wave was concentrated in greater New York (New Jersey, Connecticut, Long Island, etc.) helped lower the national sense of urgency.   

Aggressive early testing would have been confirmed that the disease was, basically, already everywhere in the country by late March, and was not, in fact, just a “Blue State problem”. The failure to deploy testing early led to a far more destructive and costly national economic shutdown than was necessary; the economic cost of a “flash depression” could have been avoided with better planning and more decisive leadership. 

But in those parts of the country initially grazed by the pandemic, an uglier reality surfaced. It was not merely a failure of leadership that hurt us but a failure of followership as well.  As protests against lockdowns proliferated, the signs told the story.  ““My Rights Don’t End Where Your Fear Starts” read one.  “Liberty for Safety- No Deal” read another.  But a sign at a “Re-open Tennessee” rally in Nashville in late April said it all in just three words:  “Sacrifice the Weak”, a jarringly un-American sentiment if ever there was one.     

In addition to underestimating their own risks, and failing to embrace measures that reduced risks for others, many of those initially spared the virus rationalized that the immediate and tangible costs to them of COVID countermeasures far exceeded the costs to others of an unchecked pandemic.  Those “others” were probably going to die anyway (e.g. older folks, people with chronic disease risks like diabetes, workers in meat processing plants, etc.) in some other part of the country that they didn’t care about. It is easy at a distance to dismiss the reality that the typical COVID fatality lost an average of eleven years of life expectancy!

Thanks to all of this, we are likely not in a second wave but rather a continuation of the pandemic in parts of the country spared the first wave.   Eighteen  states, including Texas, Florida, Georgia, the Carolinas and California,  saw increased COVID caseload over the past week.  Leaders in many states will be extremely reluctant to backtrack, and recommit their states to aggressive social distancing, which, again, would not have been necessary if they were well enough organized to test, trace and isolate- the three keys to an effective response to a viral threat.  

And it simply isn’t as if a coherent public response to this threat was impossible. Other countries (New Zealand-22 deaths, Taiwan-seven deaths, Hong Kong- four deaths) succeeded in surmounting this threat while we failed.   It’s not that the sacrifices demanded in their citizens were somehow less onerous than those that were demanded of us Americans.  What these countries did in common:  rapid diagnosis of a major threat, decisive action to sever all (not just ideologically indicated) international arrivals, universal and uncompromising lockdowns, aggressive scaling up of testing, mobility tracking and follow up.    Most of these countries were also smaller in population, had decisive executive leadership willing to take political risks and showed broad-based respect for authority in the face of the crisis.

Even though this crisis is far from over, the next pandemic is a “when”, not an “if”.  Obvious ingredients of a successful response to the next pandemic include:  multi-level planning for rapidly scalable viral testing, a secure medical supply chain,  generous stockpiles of protective gear, an agreed-upon protocol for care system deployment (to protect ongoing health care functions and workers), recruitment and training protocols for emergency workers and contact tracers and assignment of responsibility for covering high risk “hot spots” such as nursing homes, distribution facilities and food processing plants.  A thorough going and bipartisan review of the Centers for Disease Control  and a commitment to increase federal as well as state and local public health funding is also essential

In a functioning country, these would be achievable steps.   However, logical planning and decisive action may be too great a lift for a fractured, angry and distracted nation.  Two key functions- public health and law enforcement- appear to have lost legitimacy with broad swatches of the public.  Our largest political party seems to be the “Are You Kidding Me?” Party.     A failed state cannot protect its citizens against much of anything.  

A society riven increasingly by tribal resentments, fear and suspicion of any leadership is a society at risk.  The failure of the US to respond effectively to the COVID emergency is ominous, because it has shown societal divisions deep enough to paralyze the country from responding to other threats, be the other emerging diseases, a deep economic downturn, aggressive and unprincipled foreign adventurers, or terrorism foreign or domestic.   

 In the Congo, a comprehensively “failed state” if ever there was one, the unofficial national motto is:  “Débrouillez Vous”, loosely translated as “Figure it out yourself”.  This cannot be where we end up.   It seems so obvious that if we are to be an actual country,  we need to take better care of one another, and that we are stronger as a country if we trust one another and work together to address our common challenges.  

Jeff Goldsmith, Ph.D. is a health policy analyst based in Charlottesville Virginia and President, Health Futures Inc.