Aceso Under Glass

When people visit the crisis chat I volunteer at, I have three options:

1. Listen, no follow up
2. Listen, refer to specialist for concrete help (example: a woman being abused by her husband comes in to chat.  I validate her feelings and ideally help her move to a mental/emotional state where she is emotionally ready to leave.  I then refer her to the National Domestic Violence Hotline for help with the specifics of actually leaving).
3. Listen, call for emergency government interference. There are two circumstances I must do this: someone under 18 is being neglected or abused by a guardian (-> call Child Protective Services or equivalent), or I believe someone is likely to attempt suicide in the next 24 hours (-> call local 911 for an emergency rescue, high likelihood they are involuntarily committed to a psychiatric hospital).

Since I started I’ve called CPS twice and watched other people call two or three times, and never seen a 911 call.  However, I’ve talked to a lot of visitors who are really scared of me calling 911.  I have complicated feelings about this.

I believe people have a right to commit suicide.  I believe my visitors when they say that psych wards are stressful and leave them worse off than they were before.   Active rescues take away people’s power, and when so much of suicide is driven by a feeling of powerlessness, that’s dangerous.   I spoke to a woman with sensory integration disorder for whom a psych ward was pretty much hell on Earth.  If a person is depressed over money, an expensive hospital stay and days of missed work will make it worse.  

I also believe active rescue is really beneficial for some people, and we cannot perfectly predict who falls in that category.  I think it’s safe to say that people coming to crisis chat are more likely to benefit from/want a rescue than the general suicidal population, and I am ultimately willing to tolerate a certain number of unwanted active rescues in exchange for a certain number of wanted ones.

A non-trivial number of people use my chat service rather than the phone line specifically because they (correctly) believe it is harder for us to find their physical location, so they can reach out without fear of the police knocking down their door.  The fact that these people exist indicates to me that this is a good service to provide.  There is a big gap being suicidal thoughts and suicidal acts, and having place to bring light to those thoughts without bringing your world down around you can be the first step towards letting them go.

Thus far my compromise is that if a visitor is voicing concern about me calling 911 on them and telling me they do not want to be committed, I tell them how to avoid having me call.  They can tell me about their wish to die as much as they want, they can even tell me their plan, as long as they also tell me they don’t plan on acting on them in the next 24 hours.  Is it possible people will lie to me?  Yes.  And I would be sad if I found out there was a suicide I could have prevented.  But I would also be sad if an unwanted rescue kept someone from reaching out later.  And I suspect that the truly imminently suicidal are less likely to lie about it/be able to lie about it.  For one, lying is mentally taxing, and the very depressed don’t have the space cycles.  For two, lying requires planning, and the biggest risk for suicide isn’t depression, it’s impulsivity.  My hope is that the same impulsivity that causes suicide will cause people to tell me about it.  I also hope, but will never have the data to back this up, that I’ll be able to recognize impulsivity and make a different deal with the person.  I don’t know what I’d do in that case, I just have this gut feeling that all the people who’ve asked me this so far needed a sense of control more than they needed a rescue, and I’d act differently if I didn’t think that was the case.

Jezebel has a post up discussing the link between Accutane and suicide.  I link to the Jezebel post and not the new article because I find the comments interesting.

First, some background.  Accutane (generic name: Izotretinoin) is mostly an anti-acne medication, although it’s occasionally used for other skin disorders and cancers.  Depending on who you ask, it’s either a form of vitamin A or a close relative of vitamin A.  Vitamin A is fat soluble, which means if you take too much it will kill you (the livers of many arctic mammals are toxic for this reason).  One to two courses of Accutane (generally lasting 8-10 months) is usually enough to permanently cure severe acne.

Izotretinoin is a notorious teratogen, meaning it can cause serious birth defects if taken during pregnancy.  The cause appears to be that izotretinoin serves as a signalling molecule in a certain stage of pregnancy, but this is not definite.  In America, the relevant legal authority has responded with the iPLEDGE system.  Only prescribers registered with iPLEDGE can prescribe accutane. They must register recipients (with a detailed sexual and menstrual history) in the system and certify that they’ve been  warned about the risk of birth defects, and promised to take two forms of birth control.  Prescriptions must be picked up in a seven day window, lost prescriptions cannot be replaced, a prescription must be for exactly 30 days.  Recipients must take a blood (not urine) test for pregnancy every month before getting their prescription.  They recently relaxed the latter requirement for men and women of non-child-bearing age to pledge to take birth control, but still require a blood test.

This program represents some of the worst government interventions in health to me.  It imposes huge burdens of time, money, and privacy.  It infantilizes women by requiring a pregnancy test even if they report no sexual activity, yet takes their word on the whole birth control thing.  It very nearly requires hormonal birth control, and while I recognize hormonal birth control as a life changing intervention for many people, I think the dangers are understudied and under reported and dislike anything that dismisses its costs.  The timing restrictions seem to be designed to force users to adhere to pregnancy tests, which are predicated on the idea that you can’t trust women to notice they’re pregnant.  And of course, you have to do all this for people without working uteruses.  It’s also considerably more work than you need to do to take thalidomide, an even more notorious teratogen, which means the decision to impose iPLEDGE is being made based on something other than strict rational consideration of costs and benefits.

No one is quite sure how izotretinoin works.  It may induce cell death in the sebaceous glands.  It may act as an anti-microbial.  It may affect the expression of hundreds of genes.  It has shown promise as a cancer treatment, which means it probably inhibits cell growth.

Some people report that Accutane has psychological side effects, including suicide.  This is really tricky.

A lot of Accutane users are teenagers, who are already an emotionally chaotic group.  You can compensate for differing risk with a control group, but a higher variance is still more likely to lead to a false report of differing means.

Second, suicidality and depression are not as linked as you would think.  People at the absolute pit of depression are often too overwhelmed and apathetic to kill themselves. Suicide risk actually increases when treatment starts working (which may be why anti-depressants are linked to suicide in teenagers, and is definitely why mixed states are so dangerous).  Severe acne is socially isolating, which can lead to depression.  It’s entirely possible that getting better frees up enough emotional energy to feel bad, or that the first set back after an improvement feels unmanageable, and so while the drug has no direct psychoactive effects, it looks like it does through its effects on the skin.

On the other hand, it’s a known biohazard with no accepted explanation for why it works, and almost any disruption in physical systems can manifest as depression and anxiety.  The weird thing would be if it didn’t.  The Jezebel comment thread is full of people saying it induced terrifying psychosis in them.  It’s also full of people saying it saved their lives by clearing up their acne.  A 24 mouse study showed some increase in depression-like behavior in mice following injection.   An even smaller study showed that Accutane reduced cell growth in certain regions of the brain, which is terrifying for a drug we give to teenagers but hard to draw concrete conclusions from.

So what do you do, as a potential patient or parent of same, in the absence of good evidence?  Clearly you need to watch new patients closely for behavioral changes and discontinue if they occur, but what about the risk of subtle long term damage?    I don’t know how to weigh that.

Health stuff is often cyclic, and I’m in the unpleasant part of the cycle right now.  When the first derivative is negative it’s easy to feel like everything will get worse forever, so here’s a list of things that are objectively better than they were a year ago, even after the recent backsliding.

1.  My overbite.  I’ve had it since childhood.  I was prescribed braces, but my mom eventually convinced my dentist my teeth were so bad that the increase in plaque due to difficulty in brushing would be even worse for me.  Two months ago, it disappeared.  I still pull my lower jaw in when I chew because I ground my back teeth down in the pattern of my overbite, but the resting position is now almost perfect.

2.  My dental health.  I’ve had on 4x/cleanings since childhood, and my last dentist spoke in terms of great Game of Thrones like battles to fight back the plaque.  She noticed a marked improvement as soon as I went on HCl, without me telling her anything had changed.  I just started with a new dentist and he’s less bracing for winter and more trying to make sure things tay as awesome as they are now.

3.  Oranges.  I used to hate oranges.  Two or three drops of orange juice in a full glass of water were all I could stand.  Now I eat them whole, without HCl.

4.  Auditory sensitivity (increased).  When I noticed discontinuities in the sound of my last audiobook (slight changes in the volume or tone) I put it down to cheap recording not standardizing between sessions.  But my current book does it too.  I wonder if every book has these, and I just didn’t notice until now.

I am so tired of medical shows having brave doctors lie to the evil transplant committee that is heartlessly denying a transplant request because the patient is deemed ineligible due to some stupid technicality.  Most recently I saw this on House, where a woman destroyed her heart with bulimia, which is apparently a disqualification for transplant, but it comes up on practically every medical show eventually.  The transplant rules didn’t arise out of some Puritan sense of punishing people for their sins: it’s because eating disorders have a high relapse rate, and a relapse would destroy the new heart too.  By lying and getting her the heart, Dr. House killed whoever would have gotten the transplant instead. 

I’m sure that transplant committees make mistakes, that they’re manipulated by fame and money, and that the guidelines are imperfect.  But they’re not there to be mean, or to “punish” people for their transgressions.  They’re there because there are far fewer donor organs available than are needed, and in light of that scarcity, we want to make sure the organ goes to the person who will get the most additional life out of it.   If a patient has a condition that will lessen the use they get out of the heart, that lowers their priority for a transplant.

Maybe I’m wrong.  I don’t know what went into creating the rules, maybe they’re biased and terrible.  But if so, the appropriate reaction is to say that and fight them.  Not kill someone else because it will make you sad to tell your patient they’re going to die.

Similarly, House, stop lying to get ineligible patients into clinical trials.  You mean well, but there are two options:  the treatment doesn’t work, and you bought your patient nothing, or it does, and you just artificially worsened the numbers, potentially taking it away from everyone else who would have benefited from it.

The other day I posted a link to this blog post on facebook.  The post reported on a study that showed a large difference in how law partners reacted to the same paper when told it was written by a black or white student- they wrote more negative comments, were less encouraging, and found more typos.  A friend of mine responded with “I believe there is systemic racism, but…”, which is never a great start.  He went on to make a bunch of criticisms which would have been  extremely fair to make in a journal club discussing a peer reviewed study, but in context came across as reinforcing the cultural pattern of “I refuse to believe in racism is a factor until it’s proven in each specific case.” Forcing victims of systemic discrimination to prove the discrimination gives them an additional burden on top of all that discrimination.  It’s not right and it’s not fair.  It’s also heavily intertwined with the idea that falsely believing something was affected by race is worse than ignoring discrimination.  

At the same time, I dislike the argument “you’re technically correct ” (which he absolutely was- the study was done by some consulting firm and didn’t even include statistics beyond the mean) “but don’t say it because it will encourage racists.”  Nothing good comes from quieting science.

Now that I know what inflammation is and have given you my personal view of depression, I can talk about depression as an inflammatory disease.  Most specifically, the article “So depression is an inflammatory disease, but where does the inflammation come from?” from BiomedCentral Medicine.  I’ll do some additional research as warranted, but mostly I want to talk about this article.  Prepare for deep dive.

Background: We now know that depression is associated with a chronic, low-grade inflammatory response and activation of cell-mediated immunity, as well as activation of the compensatory anti-inflammatory reflex system. It is similarly accompanied by increased oxidative and nitrosative stress (O&NS), which contribute to neuroprogression in the disorder. The obvious question this poses is ‘what is the source of this chronic low-grade inflammation?’

Translation:

• As I painstakingly established last week, inflammation means a chronic dilation of blood vessels allowing more stuff to leak into tissue.
• cell-mediated immunity involves producing new white blood cells in response to a specific antigen, as opposed to producing new antibodies in response to a specific antigen, or non-specific immunity that is not a response to anything in particular (example: skin).
• Almost every system in your body is moderated by a complex series of signals that can aid or inhibit one another.  Rather than just produce less of an activator to reduce a reaction, your body instead introduces an inhibitor.   Having high levels of both activators and inhibitors has similar primary effects to having low levels of both, but can be either cause weird secondary effects or be a symptom of something weird going on.  It’s also plain more stressful, just like keeping yourself steady against a strong wind is harder than standing still.  “[A]ctivation of the compensatory anti-inflammatory reflex system” implies that depressed people are falling in the “high levels of both” category.
• In the course of the day, your body naturally produces many types of molecules.  Some of those molecules contain oxygen, or nitrogen and oxygen, and a net negative charge.  These are the home wreckers of the molecular neighborhood, luring parts of other molecules to dump their other halves and bond with them instead.  This is a problem if that other molecule is doing something important, like being the blueprint for every other protein in your body.  The damage these homewreckers cause is called oxidative stress.  Your body has ways to contain it, but not perfectly.  Oxidative/nitrosative stress can arise either from producing too many of the reactive molecules, or from a deficiency in the post-processors.
• Fun fact: we don’t know if Nitric Oxide is a pro- or anti-inflammatory messenger.  It looks the answer may be “anti- under normal circumstances, pro- under times of stress”, which implies but doesn’t prove that it’s primary effects are anti-inflammatory, but the containment mechanisms break down under stress and cause a lot of damage.

Discussion: This review explores the role of inflammation and oxidative and nitrosative stress as possible mediators of known environmental risk factors in depression, and discusses potential implications of these findings. A range of
factors appear to increase the risk for the development of depression, and seem to be associated with systemic inflammation; these include psychosocial stressors, poor diet, physical inactivity, obesity, smoking, altered gut permeability, atopy, dental cares, sleep and vitamin D deficiency.

Translation:

• Two very common bad things seem to have a lot in common.  I think there’s a lot of merit to their hypothesis, but this venn diagram does not impress me.

Summary: The identification of known sources of inflammation provides support for inflammation as a mediating pathway to both risk and neuroprogression in depression. Critically, most of these factors are plastic, and potentially amenable to therapeutic and preventative interventions. Most, but not all, of the above mentioned sources of inflammation may play a role in other psychiatric disorders, such as bipolar disorder, schizophrenia, autism and post-traumatic stress disorder

Translation:

• If we are right, this suggests several really easy ways to treat, cure and prevent depression, and potentially other psychiatric issues.

Oh wow, apparently you can induce depression-like symptoms by activating the immune system, either by triggering it with a toxin or just injecting some cytokines (a broad class of messenger, many of which signal the immune or inflammatory system) directly.  SSRIs (the most common class of anti-depressants) decrease production of proinflammatory cytokines,* and a return of symptoms is often associated with the loss of these effects.

The authors then go on to cover in detail various things you already knew were bad or good for you (Sleep- good.  Chronic stress- bad).  The research isn’t at the stage where it’s generating novel recommendations yet.  Which is not a criticism, it’s an impressive set of basic science work and it takes time to translate that into practice.If you are deeply interested in the biochemistry I encourage you to check it out, but I have no more to add.

*SSRI stands for selective serotonin reuptake inhibitor.  Because serotonin is a neurotransmitter, we originally assumed SSRIs treated depression by making serotonin more available.  Except serotonin levels change within hours of taking an SSRI, but the anti-depressant effects takes weeks to show up (unless you’re bipolar, in which case they can trigger a manic phase almost immediately).

If I’m reading this correctly, there is no bright line between acute and chronic inflammation.  Chronic inflammation is acute inflammation that didn’t go away.  Over time this may lead to accumulated effects, and the distribution of mediators and their sources may shift, but there’s a lot overlap.

There’s a few ways chronic inflammation can hurt you.  One is that is releases immune cells (aka white blood cells)  into your tissues.  Didn’t I list that as one of the features of inflammation last time?  Yes, yes I did.  When you have an infection in the tissue, you want immune cells there to go after it.  But if letting immune cells run around organ tissue didn’t have any side effects, we’d do it all the time.    Immune cells are very very good at distinguishing foreign body from host , but not perfect.  The more time they spend in the trenches, the more likely they are to misidentify a host protein as dangerous and attack.  In the worst case this triggers a really ugly autoimmune disorder.  In a milder case it triggers more inflammation.   I think you can see where this is going. So much like being in a hospital or on crutches, you want your immune cells to be circulating in tissue for as long as you need, but no longer.

Similarly, some of the proteins released during inflammation (aka positive acute-phase proteins), which do useful things like signal inflammation, coagulate blood, or retard microbial growth, can change shape* and become insoluble.  These form fibrous  masses in intracellular space known as amyloids.  Amyloids are or are associated with some of our most terrifying diseases, like Alzheimers and Mad Cow Disease, and the amyloids from inflammation can contribute to these, although they’re not necessarily the most important part.

Chronic inflammation can be self-reinforcing in other ways.  Swelling is just about the least useful reaction to an ingrown toenail, but it’s what we do.

Everything I’ve talked about so far has been local inflammation, where the reaction is contained to one identified area.  There is also systemic inflammation, in which the vasodilation is body-wide.  It’s associated with all sorts of bad things, including overeating and obesity, which immediately makes me think we don’t know the real issue because both those topics are moral panics in our society.

*Quick lesson in proteins.  Proteins are made of up a long string of amino acids.  The order of amino acids is called the primary structure.  Individual bits of those string fold themselves into 3-d structures such as the ß-Hairpin and  Greek Key.  Those structures, also known as motifs, make up the secondary structures.  The motifs in turn interact to form the total three dimensional shape of the protein, which is the tertiary structure.  The tertiary structure is determined by the electrical charges and physical shape of the primary structure.

In general, a given primary structure has a single tertiary structure, because there’s only one island of stability.  However it is possible for a second island to exist, and the protein to convert to it- either it’s more stable in a new environment, or something catalyzed the reaction and it can’t go back.  Very, very rarely, this new tertiary structure is capable of catalyzing other proteins of the same type to its new shape.  These are known as prions (e.g. Mad Cow Disease) and they awesome and terrible.

I went to an open house for a local nursing graduate school.  I accomplished my main goal, which was to learn the practical difference between an MSN, DNP, and PhD.  Answer:  any one of these allows you to sit for the Nurse Practitioner licensing exam.  MSNs are purely applied.  PhDs are mostly research although you can maybe do some application (i.e. treating patients) if you really want to.  DNPs are about taking new research and applying it.  In an ideal world a DNP and a PhD pair up and the DNP applies the PhD’s research and tells them which of their theories were killed by ugly gangs of facts, and suggests new things.  I don’t see how anyone could what something other than a research heavy DNP or application heavy PhD, but I also don’t understand how anyone could want a specialty other than psychiatry.  Which reminds me, apparently there’s a lot more funding for psychiatric NPs than any other specialty because demand so outstripes supply, because psychiatry is stigmatized among both NPs and MDs.  Which is terrible for the world but super convenient for me personally.

Meanwhile, I have my day job as a software developer.  I don’t like it, and while I could always move companies I don’t think I’ll truly be happy in any programming position and the energy would be spent on my future nursing career.  But I might as well make the most of it while I’m stuck, and I’m looking for skills I can learn now that will apply later.  There’s not a ton of overlap between medicine and programming, but one thing that is always useful is public speaking, so I’m volunteering for every public speaking opportunity I can grab.  A day after I reached that conclusion I realized social skills are also universally useful, so maybe I should stop working so very hard to avoid my co-workers.  I do not like this conclusion.  Many of my co-workers are deeply unpleasant people + office is sensory hell = I spend most of the time feeling like I’m about to be eaten by a tiger.  These are not ideal circumstances in which to learn.  But I’m told hospitals are pretty noisy too, and while I strongly feel like I’ll handle it better when it’s in service of something I believe in, greater noise tolerance would greatly expand my options.  

Of course, that’s what the OT is for.  And it’s working.  It also spontaneously corrected my overbite, which is weird because we hadn’t done anything directly to my head. But I think it’s time to take some test runs of social interactions under my control, rather than wait to have them inflicted on me.

Monday’s post was inspired by this paper on depression and inflammation.  Let’s dig in.

First question:  what is inflammation?  Allow me to translate the wikipedia article.

First, local cells detect that something is there that should not be.  Not every cell can do this.  Wiki’s list is:  macrophages, dendritic cells, histiocytes, Kupffer cells and mastocytes.  Every cell on that list is part of the immune system except for Kupffer cells, which are part of the liver.*  These cells all have pattern recognition receptors whose job is to identify molecules that represent a threat.  In a perfect world, they would recognize every threat and ignore every host molecule and harmless foreign matter.   In the real world, my body spent years convinced that tree pollen was a mortal threat and the only cure was blinding sinus pain.

When a particle activates the pattern recognition receptors they release mediators (the names, types, and specialities of these are easily a blog post in and of themselves) which cause blood vessels to increase in diameter (=vasodilation).  The most immediate obvious of this is increased blood flow, but the dilation also increases the permeability of the blood vessel walls, which allows fluid and protein to leak from the blood vessels into organ tissue.  With the help of a mediator, this also allows white blood cells, especially neutrophils ( the source of the best immune system chase scenes) into the organ tissue.  The additional fluid also increases flow to the lymph nodes, which is the in-body equivalent of getting a pathogen sample to the CDC: the lymph nodes study the fluid for pathogens in their tiny little lymph labs** and, having identified it, trigger the development of a counter-attack.    The mediators also increase the sensitivity of nerves to pain, to incentivize you not to re-injure the area.

And that’s how a physical insult becomes an acute inflammatory reaction.  If the insult is chronic, or if the inflammatory reaction becomes self reinforcing (e.g. inflammation makes an ingrown toenail more ingrown), it becomes chronic inflammation, which we will talk about on Friday, and hopefully get to the actual article on depression on Monday.

*If you’re me, you may have to remind yourself that dendritic cells != dendrites.

**Some day I’m going to learn how that process actually works and not pretend it’s a tiny reenactment of The Andromeda Strain, but the image will do for our purposes.