psychiatry

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The Medicated Woman: A Pill To Feel Better, Not Squelch Emotions

By Alicair Peltonen
Guest Contributor

I am a medicated woman. I take 50mg of Sertraline (the generic form of Zoloft) a day. I don’t take it to be more tolerable to my husband. I don’t take it because I’m embarrassed by my emotions. And I definitely don’t take it to quietly fit into a polite societal mold. I take an anti-depressant every day to quell my anxiety simply because it feels better. I feel better.

I grew up in a talk therapy household. My father began group therapy for anger management issues in 1984, when I was 10, breaking a cycle of rage and avoidance that tends to swallow people whole, particularly men. He would come home feeling calmer and then he would implore my sister and me to explore our feelings and talk about our problems. Begrudgingly at times, I learned to think analytically. And thankfully, I learned that asking for help is not only acceptable, it’s downright healthy.

I started seeing therapists here and there in my 20s and then regularly several months after my first daughter was born. Medication had never been suggested by any of my previous therapists but this time was different. I couldn’t shake the feelings of inadequacy, the certainty that my daughter didn’t like me and I was just a glorified dairy cow. Post-partum depression is a hell of a thing.

(Rachel Zimmerman/WBUR)

(Rachel Zimmerman/WBUR)

When my therapist suggested I see a psychiatrist to discuss the possibility of medication, I went home and cried for an hour. I felt ashamed, defeated, embarrassed, weak. Even though I had seen medication transform my father from a man who growled and dragged to one who laughed and hugged, it still stung to feel like I couldn’t pull myself together.

But, remembering my father’s bravery, I thought I should at least give it a try. If I didn’t like it, I could always stop taking it. The first pill was swallowed through tears. And each successive pill went down easier. For a full year, I could go days without yelling or wanting to break things and entire weeks without crying. And I felt better.

After a year, I decided to go off the medication. Things had been much better and I wanted to see if I could “go back to normal.” And things did go back to normal. But it turns out my normal wasn’t very comfortable.

There have been many discussions and articles recently asking if modern psychiatry is over-medicating women. A recent op-ed in the New York Times by psychiatrist Julie Holland suggested that many of the symptoms for which women are treated with antidepressants are natural and healthy. “We have been taught to apologize for our tears,” she writes, “to suppress our anger and to fear being called hysterical.”

Here’s the thing, though. Breaking down into uncontrollable tears because you stubbed your toe and it’s the straw that broke the stress-camel’s back doesn’t feel good. Continue reading

Toward A Less Invasive Mode Of Deep Brain Stimulation

Imagine this futuristic tableau: A severely depressed person walks into her doctor’s office, sits in a specially designed chair with a coil around her head, and with little more than an IV injection, undergoes deep brain stimulation to treat her deep, dark psychological illness.

Well, that’s not going to happen any time soon, but engineers at MIT are working on the building blocks that could make that fictional scenario a reality.

They’ve developed a method — a proof-of-concept, really — to stimulate brain tissue using external magnetic fields and injected magnetic nanoparticles that resemble small bits of rust. This technique allows for direct stimulation of neurons, which could someday be an effective treatment for a variety of neurological diseases, like Parkinson’s, and even further in the future, for severe, treatment-resistant psychiatric disorders like depression, without the need for highly invasive brain implants or external connections. The research is published in the journal Science.

(Allan Ajifo/Flickr)

(Allan Ajifo/Flickr)

Current treatments have been effective in reducing or eliminating tremors associated with Parkinson’s but involve major brain surgery to implant wires that are connected to an outside power source.

Polina Anikeeva, an assistant professor of materials science and engineering at MIT, says the new research suggests a much less invasive possibility. I asked her to describe the research in an accessible way and here’s what she said:

First, I want to clearly say that we are still very far away from any clinical or even pre-clinical application, this is a first proof-of-concept study, looking at the possibility of using these materials to stimulate neurons deep in the brain.

What we’ve done is to give a simple injection of nanomaterials (iron oxide) that look like small bits of rust [but aren’t actually rust], deep into the brain. This allows us to deliver stimulus using a magnetic field, which is converted into heat by the little rust particules. Now we have a system where a magnetic field is applied from the outside and with a simple injection of the materials we can deliver the stimulas deep in the brain without the connectors and without the implants. We don’t have to be invasive in order to do the stimulation.

Continue reading

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Growing Burden: Toll Of Major Depression Now Put At $210 Billion A Year

(Wikimedia Commons)

(Wikimedia Commons)

For more than two decades, Boston economist Paul Greenberg has been calculating the costs of depression — the mood disorder, that is, not the economic downturn.

His latest study, now out in the Journal of Clinical Psychiatry, finds that major depression is costing the American economy $210.5 billion a year — boosted dramatically by the toll of the recent recession. And rates of depression particularly shot up among people over 50.

I asked Greenberg, head of the health care practice at the Boston economic consulting firm Analysis Group, to elaborate. Our conversation, lightly edited:

First, what would you most highlight from your latest findings?

There are many highlights but I’d focus on two. The first is that the costs of depression are large and growing. And the second is that costs of depression are borne in the workplace in a very dramatic way. There’s no employer that’s exempt from the costs of depression. And I think both the magnitude of costs generally, as well as the costs that are specific to the workplace, are worthy of further attention, further thought, further research.

What are a couple of the specific numbers that you find most striking?

Let’s start with the overall finding: We find the costs of depression to be approximately $210 billion per year. One of the interesting aspects is that only 40 percent of those costs are actually attributable to depression itself.

Could you explain that?

That means that 60 percent is attributable to elevated costs that, in the data, don’t show up as directly connected to depression, but they’re associated with depressed people to a greater extent than with non-depressed people.

Economist Paul Greenberg (Courtesy)

Economist Paul Greenberg (Courtesy)

To be more concrete, on the mental-illness side, there are an awful lot of co-morbid anxiety disorders, a lot of co-morbid PTSD-associated costs — those are examples where the same person who suffers from depression tends to have a higher likelihood of also incurring costs in these co-morbid categories.

But should those costs really count toward depression, when it’s technically another disorder that’s causing them?

Fair enough. That’s part of the age-old question of to what extent is this cause and what’s effect. Take the example of someone who suffers from cancer. It could be that in some instances, there’s an elevated cost of depression when you suffer from cancer. That’s one causal pathway where the depression likely follows the physical disorder. But in another instance, it could be that back pain or sleep disorders or migraines – those are examples of elevated physical disorder costs that accrue to depressed patients, likely as a result, at least in part, of the depression.

Here’s why it matters. If we’re more successful at treating the depression, there’s little or no hope it will alleviate any of the cancer costs. But if we’re more successful at treating depression, there’s a great opportunity to alleviate some or even a large part of those back pain, sleep disorder and migraine kinds of costs that are currently co-morbid with depression. Continue reading

Blue/Black Or White/Gold, And Why Care? A Neuropsychiatrist Examines ‘The Dress’

Sometimes it just seems like the whole world has gone crazy. Like when your colleagues, all serious people, cluster for precious minutes around a computer screen debating the color of a dress. And you see that, online, many other serious people are doing the same thing — say, at On Point or The New York Times.

So though I was curious about the science behind the recent viral phenomenon known as “The Dress,” my first question for Boston-area neuropsychiatrist Dr. Jon Lieff was a more mundane “Why?” To quote one top Slate commenter, “How is this a thing?”

Not that it’s a bad thing. The dress phenomenon “informs people that perception is not what it seems,” Dr. Lieff says. “We think we see reality when in reality, what we see is what the brain wants us to see. And that leads us into philosophy…”

But let’s not go into philosophy just yet. (And you can read Dr. Lieff’s thoughts at more depth on his website, Searching for the Mind.) Let’s talk instead about why this of all optical illusions swept the Internet.

His bottom line: “Our brain is correcting for an imagined light source. That’s the problem.”

And what’s unusual about it: “This doesn’t usually happen with an illusion: In any crowd, you have half the people saying one thing and the other half saying another thing. And because of the type of illusion it is, once it’s fixed, your brain is going to keep you on the blue side or the white side. I’m sure you’ve seen other kinds of illusions where it flips back and forth.  This is different. Once people choose their sides, they’re saying, ‘This is it, and I’m the right one and you’re the wrong one.’ So it’s captured the imagination, but in truth there are hundreds of these occurring all day long, that people don’t realize.”

“An example: if you’re watching a waterfall on the TV and your hand is on the desk, your hand thinks the desk is rising up. Continue reading

On ‘Radio Open Source,’ An Intimate Look At Decades Of Depression

I’ve never met the Cambridge-based writer George Scialabba, but now I can’t stop thinking about him.

About his personal psychiatric records, from his decades of treatment for depression, so courageously shared in a recent piece he wrote in The Baffler: “The Endlessly Examined Life,” subtitled “A Most Chronic Depression.” And about his extraordinary recent interview with his friend, Christopher Lydon, on “Radio Open Source.” You can hear it in the podcast above.

Writer George Scialabba (Courtesy Radio Open Source)

Writer George Scialabba (Courtesy Radio Open Source)

The conversation is interspersed with dramatic readings of excerpts from George’s medical records, and it includes a bit of kind encouragement from one who knows:

One of the things that hurts most about depression is that you don’t really believe that it’s ever going to go away, get better. It just doesn’t seem like something with a plausible cause. So you can’t imagine what the remedy is. So people should tell you: “Look, eventually, everybody gets a little better. Some people are still mildly depressed, but virtually no one is acutely depressed for decades and decades — their whole life. It’ll get a little better, and probably a lot better. So hang on.”

So many of us know depression personally — one in 10 Americans, by an estimate that must set the bar very high — that I expect this powerful, double-platform exploration of George Scialabba’s experience will elicit very varying personal responses. “Radio Open Source’s” post about the interview includes just one comment, at last look, but it’s a gorgeous one, including this:

Well, you would think that this subject is not where you want to go in this particular winter of 2015. But it’s not about depression. Or not about only that. What it’s really about is what happened in spite of it or because of it; what happens climbing out of it, or trying to. I have had to learn and will probably have to learn again that we are not only our particular illness. It’s the illness, the suffering, the pain, which you can never convey (but need to try) even to the most sympathetic, that pain itself that is the door through which you walk to somewhere else. But also I think one needs to have something to grab onto — maybe the rope of creative expression and reaching out. Something.

One brief personal reaction: I like George’s theory that depression may be the result of faulty emotional “shock absorbers.” But I was most struck by the possibility that, after he ended his intense involvement in the religious order Opus Dei, he never fully recovered because he needed that involvement, perhaps that faith, to face life. He had a great big Human Condition problem more than a personal psychological problem. Just a thought. But it’s what I find most echoing in my mind. That, and the fact that his psychiatrists seemed to mean very well, and some surely did help him, but they came nowhere near a solution to the enduring mystery of his long emotional suffering.

Read excerpts of George’s medical records in the Baffler piece here, listen to the podcast above, and please share what echoes most for you.

Further listening: “Radio Open Source: The Untethered, Untenured Mind

Anorexia: Potentially Deadly, Treatable And Still Not Always Covered By Insurance

(Mary Lock/Flickr)

(Mary Lock/Flickr)

By Drs. Gene Beresin and Steve Schlozman

People die from Anorexia Nervosa.

This is true of other psychiatric syndromes, but with anorexia, the cause of death couldn’t be more straightforward. People with anorexia literally expire from the complications of malnutrition.

They starve and they die.

Your heart cannot beat if you don’t feed it. Your immune system can’t protect you without food. Your bones crumble, your kidneys fail, your liver sputters and your brain wanders, all as a result of inadequate food.

Suicide is common. Without proper nutrition, depression is prominent and thinking is blurred. Coping mechanisms falter. Life can seem unlivable.

So, here’s the really strange thing about anorexia: Despite its awfulness and potentially fatal outcomes, despite a death rate more than 12 times higher than any other psychiatric syndrome, insurers still balk at providing adequate coverage.

In 2008, the Federal Mental Health Parity and Addiction Equity Act put special restrictions on the coverage of the treatment of eating disorders. While the explanations for this exception vary — some have suggested that this is because eating disorders are thought to lack a biological basis — it is clear that getting standard of care treatment for anorexia remains problematic even to this day.

In 2010, the U.S. Court of Appeals for the 9th Circuit found itself facing what was essentially a logic problem. The case of Harwick versus Blue Shield of California noted that while the insurer agreed that the residential treatment requested for a patient with anorexia was medically necessary — thus making it in compliance with existing parity statutes — coverage for residential treatment was not authorized because residential treatment was not part of the health plan. The court ruled in favor of the patient in this case, but the fact that this even ended up in court is shameful. Can you imagine an insurer refusing to pay equally for the medically necessary care of any other disease with such clear risks?

So, while patients, their families and physicians continue to fight for coverage, we know that treatment for this disorder can be life-saving.

In this context, here’s the story of a young woman who recovered.

Nicole (who asked that her last name not be used) is a remarkable 16-year-old. She is academically and socially accomplished and she speaks with wisdom that belies her age. She also faced Anorexia Nervosa head on and here discusses her struggles with humility and insight.

What we can learn from her story?

To begin with, we can acknowledge that her bout with anorexia has not been easy. She suffered significant depression and even suicidal ideation as she muscled through the course of the illness. This aspect of her history is perhaps the most important take-home message. The work towards recovery from an eating disorder is never straightforward. Each patient finds a unique way to work with his or her treatment team and family to progress towards health. We can also note that Anorexia is a typically insidious and largely unconscious development. As you can hear from Nicole, the syndrome essentially snuck up on her and her family. Continue reading

A Miracle Drug For Binge Eating? Not So Fast, Says Therapist

(Bloody Marty/Flickr)

(Bloody Marty/Flickr)

By Jean Fain
Guest Contributor

For more than 20 years, my binge-eating patients have wished for a magic wand. And for all that time I told them there is no wand — there are only strategies that require awareness and effort to get a handle on their eating.

Last week, when the FDA announced it had approved Vyvanse for the treatment of binge eating disorder (BED), I found myself at an uncharacteristic loss for words. With headlines touting a magical cure for this most common adult eating disorder, I feared there was nothing I could say to stop the stampede for this next, new drug.

The news, in and of itself, is hopeful. Vyvanse (lisdexamfetamine dimesylate) has been the subject of rigorous research, first for ADHD, and now for BED. In two good-sized studies with more than 700 adult participants diagnosed with moderate to severe binge eating, this central nervous system stimulant proved more effective at reducing binge days per week than placebo for three months.

What’s more, the FDA’s approval has proven a good opportunity for a drugmaker, U.S-based Shire, and leading eating disorder associations — the National Eating Disorder Association and Binge Eating Disorder Association — to coordinate a nationwide educational campaign. If even a fraction of the estimated 2.8 million Americans diagnosed with the disorder get help as a result of the campaign’s public service announcements and new website, there’s reason to be hopeful.

There’s also reason to be cautious. Consider some of the issues before you take tennis great and Shire spokesperson Monica Seles’ advice to “talk with your doctor.” To help you do that, here are the pros and cons in my clinical experience and that of my colleagues.

But first, if you’re unclear on what constitutes binge eating disorder, here’s how the Binge Eating Disorder Association defines it:

“Routinely eating far more food than most adults would in a similar time period under similar circumstances.” Binge eaters typically feel out of control during a binge, and afterward, they’re consumed with guilt, self-disgust and embarrassment. Other hallmarks of the disorder: eating extremely fast, in secret, to the point of uncomfortable fullness, even when not hungry. Unlike other eating disorders, people with BED don’t try to “undo” excessive eating by throwing up, taking laxatives and other excessive actions.

OK, so here are a few points to consider…

Pros:

•More Treatment Options

With the FDA’s first and only approved medication for BED, patients now have another way into treatment: their family doctor. Rather than seeking out a psychotherapist or a nutritionist, which many are reluctant to do, they might feel more comfortable asking their physician about a prescription and other treatment options for this lesser-known eating disorder, which was only recognized two years ago as a distinct disorder by the American Psychiatric Association.

•Fewer Binge Days

Vyvanse has been shown to markedly reduce, if not eliminate, binge episodes in two studies, both funded by Shire. According to last month’s JAMA Psychiatry study, participants who got a daily dose of 50-70 mg, reduced the frequency of binge days per week from about five to less than one over the course of 12 weeks. By comparison, those taking placebo continued to binge more than two days per week. What’s more, half the participants taking the 70 mg dose stopped binging after four weeks, compared to one fifth of those taking placebo.

•Possible Weight Loss

Because Vyvanse has yet to be studied as a weight loss aid, it’s approved only in the treatment of binge eaters, not the overweight or the obese. That said, study subjects who took Vyvanse lost about 10 pounds. The potential weight loss may come as welcome news to bingers taking an off-label prescription for an antidepressant or anti-seizure medication. A common side effect of most antidepressants is weight gain. While binge eaters are often thrilled with the weight loss that the anti-seizure drug Topomax can facilitate, they’re none too pleased by the mental impairment.

Cons:

•Greater Risk of Abuse/Dependency

There’s a reason Vyvanse is a controlled substance with a black box warning. The potential for abuse and dependence is a real risk. Take it from psychiatrist Daniel Carlat, editor in chief of The Carlat Psychiatry Report, who expressed his reservations in a recent email exchange:

“I’m concerned that the FDA’s approval of Vyvanse for binge eating disorder is going to worsen our problems with stimulant abuse,” Carlat says. Continue reading

Could Tsarnaev Argue, ‘My Immature, Pot-Impaired Brain Made Me Do It’?

In this courtroom sketch, Boston Marathon bombing suspect Dzhokhar Tsarnaev appears in federal court in Boston for a final hearing before his January trial. (Jane Flavell Collins/AP)

In this courtroom sketch, Boston Marathon bombing suspect Dzhokhar Tsarnaev appears in federal court in Boston for a final hearing before his January trial. (Jane Flavell Collins/AP)

By Judith G. Edersheim, JD, MD
Guest contributor

This week marked the start of what promises to be a four-month public reckoning: the trial of alleged Boston Marathon bomber Dzhokhar Tsarnaev. If the press reports about the evidence against him are accurate, most of the trial will not be about guilt or innocence; it will be about sentencing. Not a who-done-it, but a why-done-it.

If Tsarnaev is found guilty, the death penalty will be on the table, and the proceedings will turn to a grave question, part jurisprudence and part moral philosophy: Is this defendant the most evil and culpable of all? A human being who deserves the most severe of all punishments?

One thing, I believe, is certain: If this case proceeds to the sentencing phase, the black box everyone will be talking about will be the cranium, and how the brain drives behavior will be the central story.

In these protracted sentencing hearings, the scales of justice balance lists of aggravators and mitigators, all outlined by law.

Aggravating factors in this case might include the political motive for the bombings, the risk posed to others during the course of the Tsarnaev brothers’ dramatic attempt to flee, the “heinous”, “cruel” or “depraved” manner of the crime’s execution, and the substantial planning and premeditation that might have preceded the bombings.

In the end, behavior trumps brain scans.

Mitigating factors — factors that weigh in favor of life in prison rather than a death sentence — cast the broadest net. Any aspect of a defendant’s background, record, character or circumstance is fair game for the defense team. It could try to demonstrate that Tsarnaev had some kind of impaired capacity to appreciate that his acts were wrong or illegal, or that he was under some kind of demonstrable duress. It could also bring to light hardships during his upbringing that limited his opportunities or narrowed his ability to choose wisely.

The defense team has already given public hints as to the central themes of its mitigators. They will feature life within the Tsarnaev family, including Dzhokhar’s relationship with his parents, his brother Tamerlan, and his sisters. Will anything in these family dynamics rise to the level of psychological duress or impaired capacity? There will likely be plenty of traditional testimony from forensic psychologists and psychiatrists regarding whether or not Tsarnaev was under the sway of his radicalized and perhaps dominant older brother, particularly after the Tsarnaev parents left the country. The prosecution will likely counter with a line of evidence regarding Dzohokar’s relative independence and his network of friends and activities outside of the family structure.

Then comes the brain.

Judy Clarke, lead defense attorney and one of the nation’s premier death penalty litigators, will surely not overlook the new body of neuroscientific evidence regarding the immaturity of adolescent brains. In a recent trilogy of cases (known as Roper, Graham, and Miller ) the U.S. Supreme Court was influenced by neuroscientific evidence about the juvenile brain when making sweeping changes in how adolescents are tried and sentenced. The court concluded that adolescent brains were less mature than those of adults in ways which warranted differential treatment under our criminal laws.

Although Tsarnaev was 19 at the time of the bombings, his lawyers might argue that much of this brain research applies, as it outlines a period of relative immaturity that stretches from mid-adolescence all the way into the early 20s. Generally speaking, this research shows that adolescents are less mature, and they are more likely to make ill-considered decisions. They bow to peer influences and respond excessively to thrill seeking and immediate rewards. Think money, sex, drugs and friends.

Beginning in the teens, there are major changes in brain architecture and function that temper these qualities — among them, synaptic pruning of the prefrontal cortex, improved connectivity and changes in dopamine receptors — all of which support self control, delayed gratification and the development of a moral compass.

Here’s the rub. What the research doesn’t show makes it problematic for defense attorneys. The research does not show that adolescents are incapable of making well-considered choices. Quite the contrary. Continue reading

Related:

Beyond Sexual Assault: How One Victim Evolved Into An Activist

Ali Safran founded a website dedicated to supporting victims of sexual assault. (Courtesy of Erinn Lew)

Ali Safran founded a website dedicated to supporting victims of sexual assault. (Courtesy of Erinn Lew)

By Dr. Gene Beresin

Alison Safran is a 22-year-old who graduated from Mount Holyoke College in May 2014. She was the victim of a sexual assault as a senior in high school in one of Boston’s suburbs.

She initially didn’t confide in her parents because she was unsure that they’d understand. However, when her symptoms of post-traumatic stress disorder (PTSD) increased, she sought help from a clinician who referred her to the psychiatrist she is currently seeing. She has since improved immensely.

Ali’s story is about her resilience, but it’s also about how good can emerge from a terrifying experience.

Symptoms After An Assault

“After I was assaulted,” Ali said. “I developed what I now understand as PTSD symptoms, but at the time, I didn’t even know what PTSD was. I was miserable. My symptoms continued into my first year of college, which made an already stressful time even more difficult. It was hard to sleep and function normally.”

When Ali attended a local university, she was assigned to a co-ed dorm, under the conditions of her housing contract. This situation was not easy for her; her PTSD was at its peak and she filed a criminal complaint against her assailant, adding more stress to her life. It was very difficult for her to live near male students who were often partially undressed in the common room.

“Even though living in a co-ed dorm is a normal part of college life, dealing with being around men while I was engaged in the criminal justice process made me feel unsafe,” she said.

Stress Of A Co-Ed Dorm

While Ali, her parents and even her psychiatrist tried to release her from her dorm contract, the university declined until eventually the administration was persuaded to alter its stance by a member of the Board of Trustees. Ali felt that though her professors were understanding and helpful in providing accommodations when needed (i.e. missing class for court), the university administration itself did not understand or appreciate the impact of her living situation given the sexual assault and upcoming trial.

“My stress level was already far above that of the average college freshman. Despite the legal process I was pursuing, my school could have at the very basic level chosen to help me relieve some of that stress. It chose not to do so,” Ali said.

The unfortunate failure on the part of her university preceded the recent focus on college campus sexual assaults, in which awareness has increased and schools are beginning to take steps to address the widespread problem. Continue reading

Persistent Stigma, Skepticism About Mental Illness Causes Real Harm

By Dr. Steve Scholzman
Guest Contributor

Profound misunderstanding about mental illness — its causes, its legitimacy and its treatment — permeate our culture. And the stigma that accompanies this lack of understanding hurts, a lot. Take this example — hardly original or rare.

Imagine a 15-year-old adolescent girl with fairly severe depression. She may be a classmate of your child, or the daughter of a friend. Let’s call her Sally.

Sally’s not so ill that she needs to be in the hospital, but she’s close. Her family and I — her psychiatrist — are doing our best to get her better as quickly as possible so she can get back to school. She’s been out now for about three days. Why? She literally lacks the capacity to think clearly. It’s all she can do to drag herself out of her bed and run a toothbrush across her teeth.

(Michael Summers/Flickr)

(Michael Summers/Flickr)

There’s a big family history of depression so Sally’s parents are both familiar with and frightened by her struggles.

“Can you call the school and ask them to give her more time on some work?” the parents ask.

“Sure,” I say, and I get in touch with the school administrator.

“Well,” I’m told by the very well-meaning administrator, “It IS a tough time of year. The other kids are getting through it somehow. I don’t see why she should get special treatment.”

“Because she has the equivalent of the flu,” I say. I like to use analogies at these crossroads.

“But the flu feels awful. Does she have a fever? Because if she does, she shouldn’t come to school…”

“No, she doesn’t have a fever,” I say. I try another analogy. “What if she had been in a car accident, God forbid?”

“Well, that’s pretty different, isn’t it?”

“How?” I ask.

“She’d be hurt,” I’m told. “This is an entirely different thing. You’ll need to get her pediatrician to call.”

I ask the pediatrician to call, and I can feel his discomfort over the phone. “I’m not very good at making this case,” he acknowledges. “It’s probably better if you just call them back.”

(I have to wonder whether he’d be so uncomfortable if I were a gastroenterologist asking him to call the school about a patient with ulcerative colitis?) Continue reading