Providentia

Quebec Expecting Federal Approval for Supervised Injection Sites

While Stephen Harper's Conservatives adamantly opposed allowing the opening of supervision injection sites in cities across Canada, Quebec health care workers are hoping that the new Liberal government will permit Montreal to become the second Canadian city to run the controversial harm-reduction program.  So far, Vancouver remains the only city in North American offering supervised injection under medical supervision , the Insite clinic in downtown Vancouver.   Despite numerous court challenges by the Federal government, the clinic continues to service thousands of chronic drug users every year and remains a model for harm reduction advocates from around the world.

Shortly before leaving office however, the Conservatives passed tough new legislation creating significant  legal hurdles for applicants seeking to opening similar centres in other cities.  One application  by Cactus Montreal seeks to open three fixed safe-injection sites in the city along with a mobile unit.    Since launching North America's first needle exchange program in 1989, Cactus Montreal has been at the forefront of health care for drug users and sex workers endangered by blood-borne diseases.  

While attempting to open a safe injection site since 2010, efforts have been stonewalled by the Federal Conservatives.  Now seeking approval for their application by the new Liberal government, Louis Letellier de St-Just, a founding member of Cactus Montreal is hoping to have their new sites up and running by next fall if approval comes quickly enough.  "The project will certainly get the go-ahead from the (new) federal health minister so we are thrilled," he said in an interview with CBC News.

But Montreal mayor Dennis Coderre may not be willing to wait that long.   In a joint news conference with then-Liberal leader Justin Trudeau last September, Coderre said that he will give the Federal government until the end of the summer of 2016 to approve the new clinics.  If approval fails to come, he vowed to open the clinics anyway.  "It's about public safety," he said. "It is about public health. And all we are asking is to be consistent with what the Supreme Court has said."   As for Justin Trudeau, he had nothing but praise for Coderre's determination and stated publicly that he looked forward to supporting him if the Liberals formed the new government. 

Still, despite the apparently unanimous support for the new sites, Health Canada refused to comment publicly on Montreal's application or how the new sites would be funded (Vancouver's Insite program is funded by the province).    

In September 2011, the Supreme Court of Canada ruled that Insite should remain open since it saved lives and improved health without leading to higher crime or drug use in the surrounding areas.  As for future safe injection sites, the government was authorized to grant an exemption to federal drug laws if evidence indicates that new sites would cut the risk of death and disease with little impact on public safety.  

Along with Montreal, the new Liberal government will eventually be expected to approve similar sites across Canada.

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Dr. Fliess' Patient

By 1895, Sigmund Freud's theories of psychoanalysis and the unconscious were still in the formative stage but his revolutionary "talking cure" for treating neurosis had already made him well-known. It seemed only natural that 27-year old Emma Eckstein should seek him out for treatment. She became one of Freud's first analytic patients and he viewed her as a special challenge with her complaints of menstruation-related depression, hysterical anxiety, and frequent nosebleeds. While he believed that Emma's symptoms were psychogenic in nature, he was cautious enough to call in a specialist to rule out possible physical causes.

Enter Wilhelm Fliess. A prominent otolaryngologist who practiced in Berlin, Fliess had already formed a long friendship with Freud since they met at a conference in 1885. In addition to a shared interest in neurosis, Fliess had come up with several, unique, theories of his own which had gained him some fame. Along with his work on biorhythms, Fliess had also developed what he referred to as the nasal reflex neurosis. Essentially, Fliess regarded the human nose as being an important link to sexuality and that sexual problems could be cured by treatment to the nose. Fliess claimed that he could give patients temporary relief by anesthetizing their noses with cocaine but he also advocated a more radical solution with nasal surgery. This operation involved removing several key bones in the nose.

In Emma Eckstein's case, Fliess viewed her as suffering from nasal reflex neurosis brought on by masturbation. Whatever misgivings she might have had about the diagnosis or the radical nasal surgery that Fliess proposed were quickly overcome by Freud's recommendation that she have the surgery. It probably helped that Fliess had also operated on Freud's nose to resolve some cardiac symptoms that he was experiencing. Despite the fact that Fliess had performed few operations of this type in the past and that he would be doing the operation in Vienna where he would not have the chance to follow up on his patient, the surgery went on as planned. He removed the turbinate bone in Emma's nose and instructed Freud to follow up on her after he returned to Berlin.

Emma experienced post-surgery complications from the very beginning. Not only was there considerable pain and hemorrhaging, but pus also began coming from her nose indicating infection (this was in a pre-antibiotic age). Freud called in a specialist who inserted a drainage tube but the bleeding continued along with a "fetid odour". Another surgeon, Ignaz Rosanes, cleaned the infected area and then, as Freud later described in a letter, "suddenly pulled out a thread, and kept on pulling. Before either of us had time to think, at least half a meter of gauze had been removed from the cavity. The next moment came a flood of blood. The patient turned white, her eyes bulged, and she had no pulse." Rosanes was able to pack the cavity and stop the bleeding after a minute but Emma was left "unrecognizable". Seeing what had happened, Freud fled to another room to strengthen himself with a glass of cognac. After returning, "a little tottery" to the room, Emma dryly commented, "So this is the strong sex".

She would need that sense of humour in the months that followed.  Recovery from the near-fatal surgery was extremely slow and left her permanently disfigured. Freud found himself in an extremely awkward position. Not only had Emma been his patient, but he had referred her to Fliess and recommended the surgery that had nearly killed her. Freud was worried about his patient but he also wanted to protect his friend Fliess from accusations of medical malpractice.  In a letter that he wrote to Fliess afterward, Freud reassured his friend that "You did it as well as one could do it...Of course, no one is blaming you nor would I know why they should".

Freud's determination to protect Fliess took him to remarkable lengths. He wrote to Fliess some time later and concluded in his letter that Emma's bleeding episodes had been hysterical in nature and resulted from "longing, and probably occurred at the sexually relevant times. The woman, out of resistance, has not yet supplied me with the dates." The fact that much of the bleeding was due to the unnecessary surgery that Freud talked her into having seemed irrelevant. Amazingly, Emma Eckstein continued on as Freud's patient and she was the likely inspiration for some his later self-analyses (including his "Irma" dream).  It is a testament to Freud's reputation as a healer that Emma Eckstein viewed her treatment with him as being highly successful despite the disastrous surgery.

Although Emma recovered to some extent, she eventually relapsed and became a bedridden recluse. After seeing another surgeon and having a hysterectomy following treatment for a myeloma, Freud was furious at her belief that her condition was organic and that she had sought treatment from another doctor. In his opinion, this "ruined her for analysis", and he dropped her as a patient. Freud continued to be a significant influence in her life though and she would later recommend her nephew, Albert Hirst, to Freud for treatment in 1910. She also became a psychoanalyst in her own right and wrote a small volume on child sexuality.

While Freud's relationship with Fliess had long since soured, he continued to defend his decision to send Emma to Fliess and described her case as being one of his success stories. When Emma Eckstein died in 1924 at the age of 59, Freud blamed her later relapse and poor health on her hysterectomy. After Fliess' death in 1928, his widow contacted Freud and asked for the letters that Fliess had written to him. Freud tersely told her that he had destroyed them and tried to have his own letters to Fliess destroyed as well.  She sold the letters instead. Orthodox psychoanalysts have restricted access to these letters for decades until Jeffrey Masson succeeded in publishing the complete Freud/Fliess correspondence (he was later fired as Director of the Freud Archives as a result of his controversial works on Freud).

Since the Emma Eckstein case represents one of the few actual examples that Freud ever provided to prove the success of psychoanalysis, the fact that this success story was not such a success seemed an odd omission from Freud's later writings. The disastrous surgery that nearly killed her and the extent to which Freud concealed his own role in damaging her health was largely hidden for decades. The case of Emma Eckstein also represents a warning to health professionals about potentially harmful "fad" treatments that ultimately prove to be more harmful than the conditions they were meant to treat.

Predicting Suicides In Veterans

Combat veterans are at risk for several adverse outcomes such as posttraumatic stress disorder (PTSD), depression, hazardous alcohol use, and most critically, suicidal behaviors. The high rate of suicide in veterans has been understood as a correlate of PTSD and depression, but it is possible that certain specific types of combat experiences may lead to suicidal behaviors. Acts committed by veterans in the context of war such as killing may evoke a “moral injury,” which leads to thoughts of ending one’s life.  A research project published recently in the journal Psychological Trauma examined relationships between combat experiences and suicidal ideation (SI) and PTSD in a sample of 68 Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans (91% male, mean age = 32.31 years) who had screened positive for alcohol misuse. The researchers examined firing a weapon/killing in combat (Firing/Killing) and killing in combat (Killing) alone as predictors of SI and PTSD severity in both the full sample and men only. Results showed that firing/killing were associated with SI for the full sample and men only, and Killing showed a trend toward significance in predicting SI. Hierarchical regression analyses suggested that Firing/Killing did not predict PTSD for the full sample or men only, but Killing was predictive of PTSD for both samples.  These results indicate that there may be differences in Firing/Killing and Killing alone in OEF/OIF veterans who screened positive for alcohol misuse. Thorough screening of combat experiences and addressing moral injury in returning combat veterans may help reduce high rates of suicide and PTSD.

For the abstract

A Shock to the System

While transcranial direct-current stimulation (tDCS for short) has become more widely used to treat various neurological and psychiatric conditions, its use in improving brain functioning such as memory and attention is a bit more controversial.   Still, a recent study by researchers suggests that it can be an effective way to make human operators stay vigilant in monotonous tasks such as drone operation and cyber defense.    

Using scalp electrodes to stimulate key areas of the brain has been carried out by researchers for more than a century though it still hasn't been formally approved for clinical use by agencies such as the Food and Drug Administration.   When safety protocols are carefully followed, tDCS can usually be maintained for relatively brief periods with no negative effects (aside from occasional problems with skin irritation and nausea).   Studies have shown good results in treating depression and more mixed results for treating other conditions such as dementia, Parkinson's disease, and schizophrenia.  Tests on healthy subjects suggest that low-current stimulation to the brain can boost attention span, problem-solving, and memory though, again, these results tend to be controversial.

But what about something like vigilance?   While there are numerous tasks that we can do for relatively brief periods of time, performance often suffers if we are expected to do the same task for hours at a time without breaks.  Whether it involves operating heavy machinery or driving a car across the country, our minds have a tendency to "wander"after a while and the potential for making a mistake rise sharply with time.   Considering that some mistakes can be literally fatal, especially for military personnel, helping workers stay focused is essential.

To read more, check out my new Psychology Today blog post.

Japanese Cafe Provides Comfort for Tsunami Victims

The disastrous tsunami and earthquake in March 2011, quickly followed by a nuclear disaster that led to thousands of residents being uprooted,  has created a traumatic legacy that still lingers today.   According to Taio Kaneta, a Buddhist monk helping tend tsunami victims, many survivors have been emotionally numbed by what has happened to them.  "People lost their ability to feel," Kaneta said in a media interview.  "They became emotionless. It’s like their hearts froze to the point where they couldn't even cry.”

As volunteers were quickly overwhelmed by the sheer scope of the disaster, Buddhist monks like Kaneta needed to become innovative in finding new ways to assist people in need.   While the monks have traditionally handled funerals and helped survivors with grief,  Kaneta found that many of the people needing help belonged to different religions and different traditions.  Also, in the largely secular Japanese society, seeking comfort from religion is not as popular as it once was.

Since Kaneta is also a musician, he came up with a more eclectic solution for comforting survivors.   As he stated, "You’ve got to improvise, like in jazz. The base of what we do doesn't change. But you’ve got to groove with it.”    With that in mind, Kaneta created a rotating, pop-up cafe, that he called "Cafe de Monk."    The name is a play on words since Kaneta is a monk and the Japanese word, "monku" means "to complain."   Joined by other monks, Kaneta sets up operation at different spots in the temporary housing facilities in Yokoyama set up after the disaster. 

Once the cafe is operating, certain ground rules come into play.  First of all, though Buddhist monks provide services to visitors, often aided by practitioners from other faiths, they aren't there to preach and no religious arguments are permitted.  Instead, visitors simply eat cake, enjoy coffee, and listen to the music of Thelonious Monk.   Art therapy and massages are also available or visitors can work on beadwork.  As far as Kaneta and his fellow monks are concerned, the purpose of the cafe is to listen.  "We draw out their suffering, sadness, happiness. Really listen," he said. 

For most of the cafe's patrons, life in the Yokoyama temporary shelter is extremely difficult.   Most come from the town of Minami-Sanriku which has been largely destroyed by the tsunami.   The units where they live now are very different from the homes they once had and were never really meant for long-term living.   The worst part is the uncertainty surrounding their existence since nobody has any idea when they will be able to rebuild   After the cafe closes at the end of the day, Kaneta often visits many of his patrons at their makeshift homes, especially the ones mourning the loss of a loved one.  For them, Kaneta provides more traditional Buddhist comfort though only as patrons request. 

Part of the appeal of the Cafe de Monk is that it can cross religious boundaries and offer services in a way that government and aid agencies cannot.    Kaneta and his fellow monks admit to often feeling depleted by the burden placed on them but are still able to unwind as needed.   Taio Kaneta often plays jazz or songs by the Beatles on his guitar to deal with the stress of his responsibilities. 

But the patrons of his cafe appreciate his efforts.   As one patron said in an interview with Public Radio International, "When they do Café de Monk, a lot of people come. And we’re able to open our hearts to each other. And the monks, they’re really good at listening.”

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Animal Models of Depression: Are They Effective?

Major depressive disorder is a common, complex, and potentially life-threatening mental disorder that imposes a severe social and economic burden worldwide.  Over the years, numerous animal models have been established to elucidate pathophysiology that underlies depression and to test novel antidepressant treatment strategies. Despite these substantial efforts, the animal models available currently are of limited utility for these purposes, probably because none of the models mimics this complex disorder fully. It is presumable that psychiatric illnesses, such as affective disorders, are related to the complexity of the human brain.  A new review article in the journal Progress in Neuro-Psychopharmacology & Biological Psychiatry summarizes the animal models that are used most commonly for depression, and discuss their advantages and limitations. The authors discuss genetic models, including the recently developed optogenetic tools and the stress models, such as the social stress, chronic mild stress, learned helplessness, and early-life stress paradigms. Moreover, they also summarize briefly the olfactory bulbectomy model, as well as models that are based on pharmacological manipulations and disruption of the circadian rhythm. In conclusion, the authors highlight common misinterpretations and often-neglected important issues in this field.

For the abstract

Ending the Nightmares

"I still get nightmares.  In fact, I get them so often I should be used to them by now.  I'm not.  No one ever really gets used to nightmares."   Mark Z. Danielewski, House of Leaves.

Remember some of your nightmares?  While we are frequently told that we are supposed to outgrow our nightmares as we move into adulthood, that isn't always the case.   Just about everyone experiences nightmares once in a while and an estimated two to eight percent of adults report problems with nightmares that can keep them from getting a good night's sleep.   Frequent nightmares are usually related to emotional issues stemming from personal crises or other life problems that won't leave us alone when we are trying to sleep.   

For people dealing with trauma especially, frequent nightmares and disturbed sleep is usually one of the hallmarks of posttraumatic stress disorder (PTSD).   Not only do nightmares serve to reinforce existing PTSD symptoms, but severe nightmares can also "re-traumatize" people who find themselves re-experiencing their original trauma due to what they are experiencing at night.    Over the past two decades, researchers have been taking a closer look at how nightmares and insomnia can be treated in people with PTSD.   This includes developing specialized treatment programs aimed at helping trauma victims work through their nightmares and learning to sleep comfortably at night.

To read more, check out my new Psychology Today blog post.

Peruvian Government Launches Investigation into Forced Sterilization Program

Esperanza Huayama was three months pregnant when she agreed to take advantage of free "medical treatment" being offered by the Peruvian government twenty years ago.   Living in the northern state of Piuria, along with dozens of other women from her village, she underwent a three-hour bus ride to take her to a medical clinic.  Instead of a medical examination however, she was anesthetized and subjected to a tubal ligation rendering her incapable of having any more children.   It was only after the operation that she was even aware of what the doctors had intended.   Her child was born dead weeks after the surgery,  likely due to the medical consequences of her sterilization.

Now 59 years old, Huayama has become one of the public faces of a campaign to investigate the forced sterilization program that had been ordered by the government of then-President Alberto Fujimori.  An estimated 350,000 women and 25,000 men, most of whom came from the poorest regions of the country, were either not told that they were being sterilized or else threatened with legal punishments if they refused. 

"I didn't sign anything. They tricked us. Nurses told us we had to go to the clinic where we would be given a free health check-up, medicine and food. They said it was for our own good and well-being," Huayama, recently stated in a telephone interview with the Thomson Reuters Foundation.  "They threatened us and said those who refuse to go wouldn't get medical care in the future.   Women were crying and shouting because of the pain. We were cut quickly. They treated us like animals.  We were given no free medicine, nothing, after the surgery. When the doctors finished, they just shut the door and returned to Lima."

International human rights group Amnesty International has launched the "Against Her Will" campaign to create a national database of victims of forced sterilization and to provide belated justice to the thousands of Peruvians rendered infertile.   Amnesty International Americas director Ericka Guevara described the forced sterilization program as leaving a wave of suffering and calls for justice and reparations.  "Even though we have documented cases in other countries in the region like Mexico and Guatemala, we have not come across a situation as serious as the forced sterilizations in Peru,” she said. 

While previous administrations have launched investigations of why so many Peruvians were sterilized, there have been systematic delays with cases being opened and closed three times since 2007.   Alberto Fujimori has been imprisoned since 2007 on corruption charge but human rights campaigners are calling for criminal charges to be laid against him over the sterilization campaign.      Prosecutor Marcella Gutierrez has until February 2016 to file charges against Fujimori and other prominent government officials involved.  .

Not surprisingly, the forced sterilization campaign has become a political issue in presidential election campaigns, including the 2011 campaign with Keiko Fujimori, Alberto's daughter, running against current President Ollanta Humala.  Though Humala won the election, the promised reparations have been slow in coming.

In the meantime, Esperanza Huyama and countless other Peruvians are obliged to live with the consequences of what was done to them.   Whether they will ever see the justice they deserve is still a politically loaded question in Peru.

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Surviving Motherhood

The mother-child relationship is paradoxical and, in a sense, tragic. It requires the most intense love on the mother's side, yet this very love must help the child grow away from the mother, and to become fully independent. Erich Fromm

What can anyone really say about motherhood?   It's a job that begins before the child is even born and it never ends, no matter how "grown up" a child may think he or she is.  Though the joys that come with being a mother can be infinitely rewarding, the responsibilities involved are often emotionally draining as well.   While fathers may take on many of the tasks associated with being a parent,   mothers are most likely to be the primary caregivers for their children, especially for the first few years of life.  

And it doesn't matter how well-educated or well-off these mothers are, the burden involved can be overwhelming at times.   Survey studies show that the number of hours spent in child rearing activities has risen from 12 to 20.5 hours a week for college-educated mothers between 1993 and 2008.   For mothers without a college education, the numbers are similar (10.5 to 16 hours per week).  For fathers, on the other hand, average hours per week spent on childcare only rose from 4.2 to 9.7 hours over the same period. 

To read more, check out my new Psychology Today blog post.

 

 

The Medical Benefits of Cannabis

A recent review published in Progress in Neuro-Psychopharmacology & Biological Psychiatry discusses nature of Cannabis and cannabinoids. The duality arises from the potential and actuality of cannabinoids in the laboratory and clinic and the ‘abuse’ of Cannabis outside the clinic. The therapeutic areas currently best associated with exploitation of Cannabis-related medicines include pain, epilepsy, feeding disorders, multiple sclerosis and glaucoma. As with every other medicinal drug of course, the ‘trick’ will be to maximise the benefit and minimise the cost. After millennia of proximity and exploitation of the Cannabis plant, we are still playing catch up with an understanding of its potential influence for medicinal benefit.

For the abstract