“What’s going on”: increased rates of mental illness among African Americans

Published Wednesday, November 13, 2013

by C. Nicole Swiner, M.D., Columnist

The holidays are approaching, which, for most people, is something to be excited about. However, for many, the holidays can be stressful and a reminder of sad times or missed loved ones.

Recently, there’s been more sadness, despair and desperation in the local news. At the risk of being controversial, the mood is increasing in the black community.

Years ago, the stereotype of African-Americans and mental illness was we didn’t suffer as much from clinical depression, bipolar disorder or schizophrenia than the general population. However, we’ve seen or read about sad situations like the young black male killed at the Marriott who suffered with suicidal thoughts or the young black mother suffering from postpartum depression at the Nation’s Capitol.

The running assumption not too long ago was they would be of any other race than black. This then begs the question: What’s going on?

What stresses us out so much? Is it the feeling of discrimination, poverty, poor health, or family or marital issues? From the Office of Minority Health (http://minorityhealth.hhs.gov), it was noted that African-Americans living below the poverty line suffer from emotional and mental distress three times more than others just as poor or poorer. Even more interesting is the report that whites are twice more likely to seek help and take an antidepressant than blacks.

Why is that? Although the suicide rate for blacks in 2011 was 60 percent lower than whites, it increased for the first time since the 1990s.

Something has changed.

Is it that the stressors of the world have finally started to get more people to their breaking point? Or is it that we don’t have the same coping skills and support system we used to have in years past? I can attest to the fact, both with my patients and with talking to friends and family, that a running theme in black families is to “keep things in the house” or “behind closed doors.”

It generally was not well accepted to be willing to or at least admit that one needed a therapist or a psychiatrist. Some would even feel judged or embarrassed to admit they were seeing a “shrink” for their problems. Faith and the church fixed most issues of stress and sadness. I still believe the previous statement to be true, in that prayer and support from your spiritual base are extremely vital for happiness and survival. However, there are hopefully more people now that are open to seeing a medical professional for some of these issues as well.

No, medicine doesn’t fix everything, but counseling with an unbiased person with a medical background can be helpful. Despite what some celebrities or others in media may say, mental illness has been proven to be linked to chemical and hormonal imbalances in the body. Postpartum depression and psychosis, for instance, is a hormonal phenomenon for women that can occur until one year after a baby is born. Research has shown that schizophrenia has a genetic predisposition, meaning it can be hereditary.

Sometimes these things cannot be “prayed away,” although again I am a believer of the power of prayer. I also know there are great benefits to medical science, namely antidepressants and antipsychotics. 

I’m a proponent of both. I encourage family support, rest, meditation, prayer and exercise – always first. But if that doesn’t help you to feel less tearful, less hopeless, less worthless, less suicidal or safer, then please seek medical help. Your medical professional can provide good advice, emotional support, medication and counseling to help you work through the tough times. The goal, ultimately, is happiness and good health.

Just figure out what help feels most comfortable to you, but, please, get help. 

 

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Be honest with your doctor

After taking some time off from writing, I was asked to comment on the importance of being honest with your doctor. This can be approached from many different angles.

The simplest route is to apply the “proof’s in the pudding” explanation. This means that if testing is done, I’ll eventually discover what’s going on after the results return. In reference to this issue and my adult patients, it means there’s no use in hiding the fact that you were once told you had high blood sugar, high cholesterol or drink alcohol a little too regularly. This is easily picked up on routine screening labs when you see your doctor. Why not be forthcoming in the beginning?

In reference to my adolescent and teenage patients, it’s useless to hide or lie about the fact that you may be sexually active, smoke cigarettes or tried illegal substances because this can be discovered in blood or urine.

However, don’t get me wrong; this is a much more important issue that just getting caught in a lie by your doctor. It speaks to an issue of trust, or lack thereof. A patient is supposed to feel comfortable with his provider enough to share intimate details, even when it may be sensitive. The matter of trust can be life or death. If a patient does not have great rapport with his provider, then that provider is not the right one.

I’ve unfortunately had more than one occasion with teen patients whom I thought I had a close relationship with that lied to me about being sexually active or involved with illegal substances. In two cases I can recall, I was either told a teen patient was not having sex or she just had her menstrual cycle, so pregnancy was not a concern. However, at the very next visit, we found out she was either pregnant or had a sexually transmitted disease.

Cases like these can be avoided if you are honest with your doctor from the beginning. We could have discussed abstinence, birth control or STD prevention. We, as your doctors, are there to protect you from harm. It’s very disappointing when instances like these occur, because I talk openly and frankly about health prevention, STD prevention and other health problems that can occur from bad decisions until I’m blue in the face.

For my adults, the more transparent you are with your doctor, the healthier you’ll ultimately be. Ask that embarrassing question you’ve always wanted to ask. Just like in school, “there’s no dumb question.”

For my teens again, if there’s an issue you want to share with your doctor, it’s ideal, of course, to first discuss it with your parents. However, if you’re too ashamed or nervous to talk to them, or a more detailed answer is needed, we can politely ask Mom or Dad if it’s OK to have a private conversation with your provider so that it’s more comfortable for you. Your medical questions are held as confidential information unless in extreme or fatal situations. If Mom or Dad says no, we can all have an open conversation together. The most important thing is to have the conversation one way or another.

Dr. C. Nicole Swiner works at Durham Family Medicine, where she treats newborns to elderly patients. She and her colleagues are accepting new patients and can be found at www.durhamfamilymedicine.net.

Chronic cough

For this topic, I’ll begin with a recent patient encounter:

“11y/o male patient with history of asthma and allergies, seeing me for first time with Mom, has been seen with our providers here for the past 3-4 months for a chronic, persistent cough. In review, he was seen and treated by 2 of our for asthma and likely whooping cough with various inhalers, codeine cough syrup, Tessalon Perles (cough tabs), Singulair, Claritin, Advair, steroids and Azithromycin (antibiotic). His most recent appointment was a week ago, where he was treated a second time with steroids and antibiotics due to the persistent, dry cough occurring in fits. He denies sick contacts, shortness of breath, fever, post nasal drainage, wheezing, or night time cough. He’s been skin tested for allergies, with +horse hair and tree allergies. He notes some mild acid taste in throat occasionally. There is no smoke exposure. He never had a swab to confirm Pertussis (whooping cough infection) and a chest x-ray done in January which was negative”.

His mother and I racked our brains for the cause of his never-ending cough. It was now keeping him, a straight A-student, out of school, due to the disruption of his fits of cough. It was distracting to him and his classmates and was embarrassing. It was concerning to his mother because nothing worked. She wanted him to see a lung specialist. After various trials of cough medicines, antibiotics, asthma inhalers, and allergy medicines, the cough was non-stop.

Causes of chronic cough generally include the following: side effects from medicines, allergies and mucus production, asthma, respiratory infections, and acid reflux. With GERD, or gastro-esophageal reflux disease, there is increased acid production and decreased acid suppression in the stomach. The acid rises and ascends up the esophagus into the pharynx, or back of the throat, and irritates the vocal cords. Sometimes, it can also cause growths, or cysts, on the vocal cords, which can cause hoarseness out of nowhere, or produce a chronic cough.

For this patient, we’d already treated him for allergies, asthma, and infection multiple times. After thinking, I realized his cough probably started out as a whooping cough infection, but after many rounds of antibiotics and chronic irritation, he was likely developing some acid reflux on top of it. We tried Zantac twice a day, and his cough quickly stopped. Success! He was still seen with a lung specialist for follow up, but by then, his cough was gone. I saw his mother later and she was very pleased the cough was gone, and he could return to school without embarrassment. 

Why the long wait?!

Published Wednesday, April 3, 2013
by C. Nicole Swiner, M.D., Columnist 

Two of the most difficult things to balance as a medical provider are seeing enough patients during the day and staying on time. Patients who schedule us for care check in at the front desk (on time, hopefully) and usually have to wait a while before they are brought back to the exam room.

Once in the exam room, they still have to wait some more before seeing the doctor. This usually leads to frustration and irritation on the patients’ parts, which leads to decreased satisfaction after their visit. Why does all of this happen?

 At risk of confusing this issue even more, I thought I’d put my two cents in and see if I can clarify some things from both sides.

From the doctor’s perspective, many patients don’t realize we only have 10 minutes to 20 minutes total for a patient encounter or visit. That doesn’t mean we have that amount of time to see you; it means your ENTIRE VISIT from start to finish is supposed to be done in that time. 

So stop a minute and think how unrealistic that may be. If a patient has an appointment at 10:30 a.m. and checks in on time, there may be a three minute to five minute process of waiting in the check-in line behind other patients and getting checked in by the front desk. If their information is out of date, this has to be updated at check-in. That takes time.

Once a patient sits in the waiting room, he has to wait for the appointment ahead of him to finish. Now, stop for another minute and imagine what’s going on with the patient ahead of you; he’s waited just as long to see the doctor, if not longer and also has important questions to ask. Even though his appointment was made for “a cold,” he also wanted to squeeze in some questions about his weight, low mood and if he can also get a physical done.

For the provider, this is difficult because we all want to give our patients the best care possible and satisfy them without overwhelming ourselves and the other patients we have waiting. Patients can be forceful and demanding oftentimes or may guilt us into doing more than we should. Now, multiply that situation by 15 to 30 people we see a day.

Or, take this situation for instance, which is what happens to me more often than not: An established patient comes in for a routine “follow-up” visit. We get started, and at the very end of the visit, tears begin to fall. It’s usually in response to my asking “So, how’s the family?” or “How’s work?” or “Are you sleeping well? 

There is almost always an underlying element of stress that leads to these issues. These are also the type of scenarios that we should start with at the beginning and not at the end of the visit. As the doctor, how do I rush that patient away when he clearly needs extra time with me to vent? The answer is I can’t. It’s a very difficult but necessary part of the job of taking care of people. 

This is what I would suggest to patients to help all of us be more efficient and gain more satisfaction:

• Come to your visit 10-15 minutes early to account for standing in line, checking in and editing information at the front desk.

• Schedule the appointment for only what is needed, i.e. medication refills, physical exam/pap, cold, etc. If you have issues that may take additional time, schedule another visit.

• Start with your most important complaint first. This means not waiting until the last minute of the visit to bring up the issue that would take the most time discussing.

• Make sure all of your demographics, addresses and insurance information are up to date at the time you schedule your appointment and don’t wait until check-in.

• Ask to come in two to three days before a scheduled visit for fasting blood work, if needed. This saves time and prevents you from having to come back to discuss results, and saves back and forth phone calls from the nurse or doctor trying to reach you later.

• If your lab has the ability to send your results via Internet or email, sign up for it. This way, you get your results quicker and saves time on the phone.

• Make sure to ask for refills needed at your visit. Most “extra” time that takes away from seeing patients for the staff and providers is spent on the phone or online filling refills that could have been handled at the time of the patient’s visit.

 

“Is an IUD right for me?”

This is a question I deal with often, as I counsel frequently on contraceptive methods with my female patients. There are multiple methods, including family planning (“rhythm method”), birth control pills, barrier methods (male and female condoms, diaphragms), the patch, the “shot”, implants, and IUDs.

At my clinic, I place IUDs (intrauterine devices) of the Mirena type, which is a 5 year long, progesterone-releasing method. There are other types of IUDs, such as the copper-T and Paragard that do not contain hormones and last longer than 10 years. IUDs are not only used for birth control, but also potentially to control heavy menstrual bleeding, severe menstrual cramping, and conditions such as ovarian cysts, endometriosis, and other female organ disorders.

The following is the general information I give female patients when they’re considering this method:

We are placing an IUD today, and I hope that you’ve had a chance to review either the brochure or research online about this birth control method. Feel free to ask whatever questions you may have before our procedure.

Benefits

-We hope that you’ll be able to keep the IUD for as long as you want, for up to 5 years. If older than 35years old, it’s a good idea to make sure you include a good amount of vitamin D and Calcium in your diet as the IUD may stop your periods for 5 years, which equals a sort of “early menopause.” These vitamins help protect your bones.

As long as you have not had any ectopic (tubal) pregnancies or recurrent STDs (gonorrhea or Chlamydia), there is little reason notto have an IUD if you want. It does not, however, protect from STDs, so condoms must still be used.

Risks & possible complications

-Anytime ‘outside’ objects are introduced to our ‘insides’, there is always the potential for infection and discomfort. We do our best to keep the procedure sterile (gloves, cleaning solutions, instruments, IUD), but it is possible still. You also should have taken the medicines I have you beforehand to reduce discomfort, which can feel like strong menstrual cramping.

Also, most of the instruments used are metal but not all sharp fortunately. There is the potential for bleeding. The most concerning risk is for the instrument to break through the tissue or muscle of the uterus causing hemorrhage, which is an emergency, for which we call 911.

What to expect after the procedure-

We will make sure you feel ok before leaving Please ask for Tylenol if you feel you need it before discharge. You can expect some vaginal bleeding during the first 24-48 hours afterwards with menstrual discomfort. You can use you Ibuprofen for this every 8 hours as needed. Bed-rest is not required, but I would defer from strenuous activity. Going to work from here is fine.

Some women experience irregular bleeding for up to 3-6months after placement. After than, you’ll join 1 of 3 groups: one-third of women continue irregular bleeding for the duration, the second group continue their normal monthly cycles, and the latter one- third stop having their periods altogether. Everyone responds differently and we don’t know which group you’ll fall into until the IUD is placed. The good news is you can return to have it removed whenever you want.

If you feel back to normal after 24-48hours, resume normal activity, which includes sexual intercourse and tampon use if desired. However, you can also wait to see e at your 1 week follow-up to check the string and make sure thing are stable. Call us here if you have any questions during that week, or problems including fever, severe stomach pain, extremely heavy vaginal bleeding, or foul-smelling vaginal discharge.

Sneaky skin cancers

I’ve been fooled recently. I’ve been fooled by abnormal skin lesions of patients, and I’m not afraid to admit it. I see a good bit of dermatology in my practice, as I’m usually at the front line of diagnosis for my patients.

Here are three recent cases that surprised me.

The first is of a longstanding patient of mine – an elderly white gentleman with a rash on his scalp that we’d frozen lesions off of before, and treated as a combination of “cradle cap” and actinic keratosis, which is essentially sun damaged skin. He returned for evaluation of one lesion on the scalp that seemed to be growing much larger than the others. It was mountainous, yellow and greasy, just like a severe case of cradle cap, and similar to what some babies have.

However, since it was bothersome to him, we decided to take it off by doing an excisional biopsy. We numbed it up and cut it off and sent it to the pathology lab to grow. It returned showing squamous cell carcinoma in situ. This is a precancerous type of lesion that potentially can become cancer. Squamous cell carcinoma in situ has a high probability of becoming true carcinoma. We sent him to a dermatologist for follow up, and he is doing well.

The second patient is an elderly black gentleman I saw with our physician’s assistant. She brought him to my attention for a fairly normal-looking mole on his forehead. He’d had it for years, but it recently started changing in size, shape and color. He had no family history of skin cancers, but due to the recent changes, we agreed to do an excisional biopsy.

Guess what it turned out to be? Squamous cell carcinoma! Not in situ again but true carcinoma. That was truly surprising, particularly since he is African-American, a group that skin cancer doesn’t normally affect, and he had no family history.

The last one is actually a patient of my colleague that he brought to my attention. This is a young, white gentleman who came in for what he thought was “pink eye.” There was a dark spot beginning in the sclera or the white part of the eye, moving into the inside of the lower eyelid. It wasn’t painful, but it was new and had increased over the last couple of weeks. He had no family or personal history of skin lesions or cancers.

The first person that saw him in our practice thought enough to send him to an eye doctor that biopsied the lesion. When he returned to my colleague, guess what it turned out to be? Melanoma!

I never would have imagined skin cancer beginning in the eye. He had no other lesions on the skin that would have sparked the thought of skin cancer. I was able to see the patient and see the original lesion in the eye that was biopsied. I’ll never forget that case, and I’ll now pay even more attention to everyone’s eyes when I examine them.

The point is, skin lesions can be sneaky, and are more often more than meets the eye nowadays. This is not to say every mole, spot or skin tag is cancer, but if there is significant change in color, shape or size over a matter of months, it needs to be evaluated by your doctor. Don’t ignore your body. It may be trying to tell you something.

Dr. C. Nicole Swiner works at Durham Family Medicine, where she treats newborns to elderly patients. She and her colleagues are accepting new patients and can be found at www.durhamfamilymedicine.net.

Deer ticks, and dog ticks, and mites….oh my!

Tick season seemed to start earlier this year than usual. One of my partners in our practice in March said she awoke one morning with a deer tick, and we knew the season was here. This month alone, June that is, I’ve treated 3 cases of RMSF, or Rocky Mountain Spotted Fever, which is one of the common tick‐related illnesses we treat here. Tick‐borne illness is one of the interesting things I’ve learned about since practicing in North Carolina, as these illnesses are more common in the Southeast. But apparently they are an issue all over the US during this time. The illnesses include the above‐mentioned RMSF, Ehrlichiosis, Tularemia, and Lyme disease.

Lyme disease is actually very rare in North Carolina, because the tick that carries the disease is rarely found here. I had to refresh my memory on the different kinds and flavors of ticks, so that I could identify them on patients more easily.

The usual season for ticks is now, during the spring and summer months. The different types of ticks vary from dog ticks to deer ticks to Lone Star ticks. The American dog tick is generally a reddish‐brown color and becomes large and red after it’s attached itself and fed. Deer ticks are usually smaller and darker than dog ticks. The Lone Star tick is also small and reddish‐brown in color but usually also has a white spot on the back. Clear as mud? If confused like I was, you can go to the CDC website (Center for Disease Control and Prevention) to see pictures.

I also have a hard time identifying which is which, so I’ve posted a picture of types in my examination rooms for patients to point them out. Lone Star ticks are probably the most common type in this area, and they cause symptoms such as fever, headaches, myalgias (body aches), and possibly a round, “bulls‐eye” rash where they have bitten. This is the classic rash called erythema migrans, and it’s very helpful to see when trying to diagnose the illness. Not all tick bites will cause the illnesses if caught early enough. The best way to remove them is with tweezers and picking the whole body off, but most importantly the head. If you don’t know whether you’ve removed the entire body, don’t play around with it, have you doctor look at it and remove the rest as quickly as you see it. Don’t use matches or ointments, because they don’t work well all the time.

Once symptoms have been identified, your doctor may go ahead and start treatment, or do blood work. Labs that are affected by tick‐borne illnesses include white blood cell count, platelet count, liver labs, and sodium. There are also antibody tests for RMSF, Erhlichiosis, and Lyme disease. Once I generally have a good idea that a person has been affected, I usually will start treatment with Doxycycline, which is the most common antibiotic that treats all the common types of tick‐borne illnesses. The medicine is prescribed either for 1 or 2 weeks, depending on the severity of symptoms.

Now, to say a word about Lyme disease in North Carolina‐‐‐it’s present, but not very common. In 2008, the CDC reports 16 cases were reported in North Carolina versus 2000‐3000 cases in the upper north states of Connecticut and Minnesota. Because of its long term effects and consequences, such as arthritis and neurologic effects, Lyme disease is taken seriously, but the other types of tick‐borne illnesses are far more common than Lyme disease here in North Carolina. Be careful this summer!

Be Healthy and Be Blessed, Dr. Swiner

*Reference: www.aafp.org (American Family Physician), www.cdc.gov(Center for

Disease Control and Prevention)