Bi-coastal Issues; A Meditation on Underwear and Cheese

Today, a transition post, and it'll be short, because I have a ton of things I'm supposed to be doing, if only I knew what they should be.  It's the kind of crazed day I experience once every couple of months or so, when we move from one coast to the other.  Everybody always says how cool and glamorous it sounds to live on both coasts...the Jet Set, and all..., but it's not.  Primarily, it boils down to a collection of little annoyances, like Parmesan and underpants.

What bi-coastalism really involves is a lot of time cleaning out the refrigerator; a lot of trips to the grocery store on the other end to fill a refrigerator that I cleaned out two months ago; and an enormous amount of not having what you need where you need it.  I can never remember anymore what I left where.  Like underpants, for example...a category of clothing that I tend to play favorites on.  And this really does relate to getting older, so bear with me.  Cheese may or may not make it into the final draft, but, as of the end of this paragraph,  I was still intending to include it in this post. I've left myself a handy image reminder above.

On underwear, then. I lack consistency where underpants are involved. I may have twenty pairs of things that more or less qualify as underpants in a given locale, but fifteen of those are just Not Right, which, some mornings, makes for difficult decisions that only the elderly  and new inductees into potty training face. There's so many considerations: hip hugging or waist-high; granola cotton, familiar nylon, or sleek microweave; boy-cut (at my age!) or that Bridget Jones style?  Honestly, I never expected I'd still be trying to deal with underwear decisions again after that landmark day I decided that thongs were a tactical error. Yet, indecision can still follow me from one side of the continent to the other.

Naturally, there's the fortune-telling aspect of underwear selection.  Is this likely to be a Best Underpants kind of day or a day where I might decide to cancel everything I was supposed to do outside the house, and just veg out as only retirees can, in which case Mediocre-Or-Worse underwear will do fine? Although it has no right to, this sort of decision can eat up several minutes even on a day that doesn't involve packing. When you see an elderly woman standing frozen in front of her chest of drawers, drool hanging from her bottom lip, there's likely a big underwear issue up for internal debate.

And, when I do buy some new underwear that appears to have all the ideally desired characteristics, they often don't measure up once I get them home. (They don't let you try these things on, do they? There's a disconcerting lack of standardization in brand sizing: a pair of 6's made in China differs considerably from a pair made in, say, Czechoslovakia. Got that visual?) There's some danger that the new purchases will be so perfect that I decide to pitch all the Lesser Candidates. Or take the Lesser Candidates to the opposite coast in a fit of frugality and underpants-procrastination.  And leave them there, of course, but not be able to recall that I did, in which case, I must run out and buy some new ones, because nobody should pack to go away for 6-8 weeks without packing underpants. My mother would spin in her grave.

When I get to the opposite coast, will I have a confusingly varied number of underwear decisions to make on a given day, or will I find that I have to wash and dry the pair I wore on the plane in order to go out and buy some new ones? Right here, you can see that the first day back on the Other Coast is already shaping up for a Retiree Veg-out.  I may blame jet-lag, but you'll know better.

Parmesan presents a challenge equal to the underwear dilemma, and not entirely antithetical, but with nuances of its own.  Veteran Mature Landscapers will recall that, whatever my dietary whims of the moment, Parmesan cheese is always included. Even when I'm trying to go vegan. Unlike my Underpants Policy, which is likely to change about every two months, my Parmesan Policy is a firm and consistent thing: I try never to be without some.

 I like to invest in Parmesan by buying those huge Costco cheeses that would take a real Italian family of eight an entire year to use...none of those pre-shredded types in the plastic shaker bottles for a foodie like me.  I like the real deal, the kind you can hurt yourself trying to grate.  The ones we buy are so hefty, so costly, and so un-food-like, they remind me of the weighted hockey-puckish things they move down the ice in the curling competition at the winter Olympics.  I've usually got one on each coast...occasionally even leaving the East Coast Parmesan in the otherwise empty refrigerator, actually expecting it to be its usual, un-blemished, creamy self when I get back all those weeks later. Ew. Or vice versa. Other times, however, I recall that even cheeses the size of a dorm-room refrigerator can mold, and I gift them to an acquaintance on refrigerator-cleaning day...tax deductible.

There are so many bi-coastal land mines, I've been forced to  project them all onto cheese and underwear in the interest of time.  But this stuff is anxiety-producing; I start worrying about the Parmesan in one house while cleaning the refrigerator out in the other one.  I wish I didn't fret so.  And please, don't suggest I write it down.  I've already thought of that, but I'm afraid my kids will find a note in my cardigan pocket when they're cleaning out the house after the funeral:  "Left half a Parmesan in California, but all the underpants are on the East Coast."

I'd ask my husband again what he recalls on the cheese front from our last migration, but he's never yet guessed right on cheese; he seems to have aged out of a good, intuitive grasp of Parmesan.  It would wind up being like the five jars of olives in the refrigerator...he buys a new one every week because ,whenever he's at the store, "olives" keeps turning up as a trace memory.  And I would hate to have to call my Other Coast friends and poll them:  Did I, by any chance, give you a cheese before I left last time?  I didn't?  Fabulous!  Thank you so much!  I didn't happen to mention a sudden, radical rethinking of underwear at the time, did I?

[image credit: cache.daylife.com/.../09Cm1tOdyS4OF/610x.jpg, farm1.static.flickr.com/184/442466500_6e20887]

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And The Award For Perfect Timing Goes To...

“Any man can go up—oh, almost indefinitely—but to go down, and down sure-footed, that is another thing entirely.”  (Patrick O’Brian, HMS Surprise)


Is Newsweek saying antidepressants don’t work? Yes, they are, and isn’t that a cute cover.  Any doubt which way is up?


And are they right? This one has sent me into a flurry of research over the past two days.  My tentative answer is, They may be on to something, but watch for scholarly refutations over the next few weeks.


And, in this national climate of distress, isn’t their timing the coldest, most callous, most credulous act imaginable?  Hmmm, you think?  We’re vulnerable; we’re already worried about EVERYTHING, and we tend to believe what we read on the cover of a major news magazine, especially when big numbers are thrown at us between the covers. Thanks, Newsweek; can’t wait for your next issue!


I'm no expert, but here’s how the cover story looks to this reader:  


Irving Kirsch, PhD, of Hull University, England, is saying that his method of statistical analysis shows that antidepressants do not beat placebos by enough of a margin to justify their use in most cases. Sharon Begley of Newsweek has given him a nation-wide plug for his new book, along with a cynical and somewhat overwrought treatment of a critically important subject.  Caveat emptor, indeed, but is it antidepressants, Irving Kirsch, or Newsweek we should distrust more?


In an article written for the issue dated February 8, 2010, entitled “The Depressing News About Antidepressants,”  Sharon Begley references research done in 1998, by Kirsch and Sapirstein at UConn., and expanded by Kirsch in 2008.  Begley’s article might give the impression that Kirsch and team tested the 3000 patients themselves, which is not the case; they applied meta analysis, a statistical method, to studies published by the drug manufacturers for four antidepressants. Later, they included research that was done, but not published (leaving the impression that this research was withheld or kept secret); those studies were, in fact, sent to the FDA as part of the usual approval process for any particular drug.


Kirsch and team concluded that, of those respondents who reported improvement in placebo-controlled clinical trials of experimental antidepressant medications, the patients who got the medication improved only 25% more than those who claimed improvement on the placebo, and, when unpublished studies were included, the margin of difference between placebo effect and medication effect was reduced to 18%.  Hardly worth it, Kirsch concludes. And it does sound like big news, but, before you throw out your antidepressant and confront your doctor, there are a few more things to consider.


The implications of Begley's article are that the facts are being withheld from patients and the public, presumably by a coalition of folks in the know and on the take; to operate as a conspiracy, this coalition would have to include big pharmaceutical companies, the Food and Drug Administration, The National Institutes of Health, The American Medical Association, the medical insurance industry that (from time to time) helps pay for the medications, and individual doctors just like yours or your mother’s or your best friend’s…for a short list.  In other words, everybody but the patient.  For those who study conspiracy theory, the rule of thumb is that the more entities said to be involved in the conspiracy, the less likelihood there is that secrecy and joint action can be maintained over time…or, too many cooks spoil the broth.


The study acknowledges that antidepressants show greater efficacy rates, as compared to placebo rates, for the most severely depressed, but discounts those results by concluding that the most severely depressed patients were under-responsive to placebo.  There are lower drug benefits, as compared to placebo effect, demonstrated for milder depression


The article reminds patients who take antidepressants (and they don't differentiate between mild and severe in this warning) not to stop suddenly because, “That can cause serious withdrawal symptoms.”  There is the assumption here that patients will read the article and immediately discontinue their antidepressant because it’s been revealed that the positive effects they’ve experienced are really all in their heads. There's a greater danger that some patients will read the cover headline, alone, and, regardless of the level of severity of their depression, the benefit they may have personally derived, or the history of their own treatment response to other modalities, they'll do what depressed people are prone to do: they'll give up.


 Most patients, however, will think for themselves.  They know what they tried before they turned to medication and they know what they’ve experienced since.  In this country, with our self-reliant tendencies, we tend to go about as far as we can before we ask a doctor for help; hence the stats that everybody can agree on: fewer than half of the 13-14 million adults who experience clinical depression in this country in a given year will receive treatment of any kind and at least 32 million of us will have the disease (or disorder...and that's another blog post altogether, too).


The National Institutes of Mental Health do not recommend medication, alone, for depression.  The recommendation in clinical depression is for medication with psychotherapy and lifestyle changes that include exercise and socialization, along with conscious efforts to solve contextual problems that have led to or exacerbated the illness.  Good doctors, particularly specialists, know that they give their patients the best shot available at lasting benefit by urging their patients to follow those recommendations. Begley sloughs this off by saying, “…there’s the little matter of reality. In the U.S., most patients with depression are treated by primary care doctors, not psychiatrists.”


So, if we throw out our medications because prescribers aren’t following the national guidelines—put the baby out with the bathwater—then what? If, thanks to Begley, patients assume that their medication was no better than “expensive TicTacs,” as she calls them, will they turn to psychotherapy and alternative treatments, instead? Where I live, there is a large population of depressed patients who distrust psychotherapy far more than they do medication; without the benefit their antidepressants do afford them, they'd go on with lives that are burdensome to them, to their families, and to their employers...unrelieved.  In their cases, I'm pulling for all the good of the placebo effect plus whatever boost the medication itself can provide them.


For prescribers, the patient's willingness to engage in the slower process of psychotherapy,  the availability of sound and qualified therapists, and the patient's insurance coverage for non-medical treatments all have to factor into treatment planning.  Where psychotherapy is chosen, the doctor and therapist have to work in close consultation...a practice that typically does not occur where the referring doctor is a primary care physician. 


While Kirsch would obviously be persona non grata in the American medical community, he hasn't fared much better among academics, who have more stake in associating themselves with quality research .  When the journal Prevention and Treatment published Kirsch's paper "Listening to Prozac but Hearing Placebo," they issued a warning in print with the article stating that the authors had used their statistical analysis "controversially." Begley's article does state:

A nascent collaboration with a scientist at a medical school ended in 2002 when the scientist was warned not to submit another grant proposal with Kirsch if he ever wanted to be funded again.  Four years later, another scientist wrote a paper questioning the effectiveness of antidepressants, citing Kirsch's work. It was published in a prestigious journal.  That ordinarily brings accolades.  Instead, his department chair dressed him down and warned him not to become too involved with Kirsch.

When you read Newsweek's cover story, keep in mind:

1.     Most of the research cited here has been available for analysis since 1998; if Kirsch's method of analysis is standard and is logically applied to the data in question, are we left with no choice other than to believe the information has been deliberately withheld from us?  Both too pat and too paranoid for me.

2.    Kirsch holds a PhD in psychology. Research claiming the lack of efficacy of medications and the greater efficacy of psychotherapy and non-medical modalities has historically come from psychologists, a field which previously failed in its bid to be approved in most states to prescribe the medications it now denounces. (Exceptions: in LA and NM, psychologists who additionally complete a two year masters degree in psychopharmacology can prescribe). Most of the studies that have historically shown greater efficacy of meds over psychotherapy have been funded by medical entities.  Go figure.

3.     On his departmental website, Kirsch states,

“My main research interest is in response expectancy, suggestion, and suggestibility. Among the domains in which I investigate these phenomena are: placebo effects, antidepressants, hypnosis, pain perception, behavioural automaticity, memory distortions, complementary and alternative medicine, cognitive-behavioural psychotherapy, repetitive strain injury, irritable bowel syndrome, anxiety disorders, and depression." 

If the placebo effect can color patient response to antidepressants, can researcher bias color the interpretation of statistics?

4.    The Hawthorne effect posits that subjects can improve simply by virtue of being studied, which complicates the placebo effect numbers in studies where patients are followed over time by researchers wielding depression scales. So the placebo numbers cited by Kirsch are not so clear-cut, either. 

5.    Most importantly, Kirsch’s book, The Emperor's New Drugs: Exploding The Antidepressant Myth, was published in 2009 in the UK, but at the end of January, 2010, in the US.  Time Magazine covered this study in May, 2009, and far less provocatively. The Newsweek article is timed as a book review cum medical alarm, not as timely research news.

6.    About the only business in this country that rivals traditional medical treatment for its claim on the patient dollar is the big business of Alternative Medicine, a largely unregulated field where patient exploitation is rampant.  In an atmosphere of national distrust of the traditional medical world (not misplaced, entirely), patients are flocking, not to the trained and regulated psychologists and social workers, but to the practitioners of alternative therapies, who base their conclusions on individual patient stories…the very type of anecdotal evidence that the researchers would deny to patients trying to make actual decisions about their care today.  

7.    When Newsweek casts doubt on the efficacy of antidepressants for mild to moderate depression, they also sow those seeds of doubt, by implication, on other uses of those medications, such as in the treatment of depression associated with trauma for victims of disaster and veterans returning from war, or for obsessive-compulsive disorder or anxiety disorders.  They sow distrust between patients and their doctors.  And they sow doubt in the minds of patients who are being successfully treated.  Begley admits, "To be sure, the drugs have helped tens of millions of people." 

8.  The article makes the issue of treatment an either/or proposition: either meds or therapy.  Remember that the NIMH recommends both in combination; our attention is better placed on obtaining insurance coverage for both medication and psychotherapy for everyone in this country. The decision on whether to use meds, talk therapy, or a combination could be put back in the hands of the patient and the doctor.

At the very end of the article, Begley says, in reference to exposing the pill pushers, “Maybe it is time to pull back the curtain and see the wizard for what he is.”  Yep. I agree that blind trust is a bad idea. And that patients must learn to act as self-advocates, which means more education about their own care.  And that statistics aren’t always what they seem, no matter who publishes them.  If we’re just looking at which player in this story is most against the ropes and most likely to stretch a point for effect, I’d say the print media is the most endangered of the three…that would be Newsweek.


And somebody licked the red off Sharon Begley's sugar pill, honey, 'cause this girl is PISSED; she's got an agenda with this article.  Let's see, I think the telltale phrase was, "drug so strong it's making me vomit or hate sex."  No, maybe the giveaway was her two references to Dumbo the Disney elephant to describe people who believe in their medication.  And this is the cover story of a major news periodical?  Now, I'm really worried about America.


Do you know someone who has been helped by medications for depression?  How do you think they would react to this article? Do you distrust anything the FDA approves, period?  Does Newsweek have a bias other than a desperate need to sell magazines? Could they possibly have picked a crappier time to go to press with this on their cover?

 [image: http://psy.hull.ac.uk/Staff/i.kirsch/#L2]

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She's Got Leg

One of the advertised goals of Mature Landscaping is to describe aging from a personal perspective, so that 1) those of you who are doing it in tandem with me can feel genuinely okay about yourselves, safe in the knowledge that, if it’s happening to somebody who publishes a blog on the internet, it’s got to be normal, and 2) those of you who have yet to participate in aging can look forward to it, confident that you’ve been warned.

Continuing the tradition of journalistic excellence in pursuit of that goal, we have embedded ourselves, at considerable risk, in an iconic twenty-year-old, 2200 sq. footer with a rusting For Sale sign out front, located in a typical middle class retirement destination in a third-world  Red State, slap in the middle of Fixed Income Hell…the front lines. It’s happening here first, folks, and, when it does, we’re bringing it to you.

Today, we’ll chronicle an under-reported phenomenon that’s widespread in my age group: the aging body has the ability to hurt itself doing absofrickin’lutely nothing whatsoever. And doctors will make it worse. 

[We at Mature Landscaping have issued a policy statement to the effect that we are unanimously in favor of healthcare reform, but we firmly believe that there ought to be some healthcare, first. We know our job is just to report the news as accurately as possible; we leave the conclusions up to you (and we’re the only news source that does. You’ll have an opportunity to make valued input at the end of this report)].

We…well, since I was by myself at the time, sadly…I was taking a shower the other day, doing nothing inappropriate or useful (staring blankly into space, momentarily unable to recall what I was supposed to be doing, and letting the hot water run low). I was standing perfectly still and my right Achilles tendon injured itself. Suddenly, for no reason, and with pain involved. I couldn’t even put my weight on that foot  without hot, stabbing pain shooting up my calf, so I did the usual Puritan thing and tried to ignore it for a few days…an approach that I remember working really well until I turned fifty-five, and one which I’ve applied with some degree of success to almost every physical condition except labor.

After about three weeks, when I’d gotten tired of limping pitifully and of receiving the kindly attention of my friends (and they’d begun to tire of giving it), I saw an ortho/sports medicine specialist who X-rayed the bone and used Doppler to rule out a blood clot. Then he sent me home with this honkin’ huge, heavy, awkward, black, rigid, ugly-ass, knee-high boot cast and told me to wear it 24 hours a day except in the shower for six weeks. Weeks. Six.

With help, I strapped in and took The Boot for a couple turns around the office, quickly ascertaining that the booted right leg was about three inches longer than the left one. And, that I couldn’t lift the booted leg high enough with each step to be sure I cleared the floor…at least not in anything approximating a gait that I’d want anyone to witness or that might propel me in an actual direction.  No matter what I tried, I drug the sole of the boot a little with each step. I hung. I tried swinging the booted leg out wide to the side, sort of like Chester in “Gunsmoke,” but that quickly caused a searing pain in my right hip. Doc said I could look for “a sneaker with a really thick sole” to even out the legs “so I could walk normally.”  Who makes a sneaker with a three-inch sole?!  For that matter, who the hell still calls them sneakers…a sports medicine doctor?! I knew right then that about the only time I was likely to be willing to wear The Boot was while I was IN the shower standing still and that compliance with this quack’s instructions guaranteed that I would fall and break a hip before I got to my car in the parking lot.

After the doctor had left the consulting room—apparently satisfied with having produced another grateful  patient on her way to a sure cure—I was left with the nurse who had brought me the paperwork and the invoice for The Boot.  I tried a few more steps, hung the boot up on the leg of doc’s swivel stool, and saved myself from a fatal fall by grabbing hold of the nurse. She was a tiny little blonde thing who popped gum and reminded me of…what’s that tiny little blonde’s name who played June Carter Cash in that movie called what’s-its-name? Once we unraveled ourselves, I tentatively suggested that I might not be able to cope with my new boot and asked if Nurse June had any suggestions.

 

June left the room and I heard her tell Doc (cue the sarcasm), “Hey, she don’t wanna wear the boot! (Inaudible grumble from invisible doctor.) Hey, I dunno, she just don’t like it, I reckon. Pop.” Doc wheels in, all 6’4” of him, looking severe in his lavender shirt, matching tie, and black crew cut (who’s his style consultant, honey?) and says, “What’s this I hear about you refusing to wear the boot?!? “

I took the boot. Yeah, I know, you wouldn’t have, but I am a passive-aggressive Southern female; we like to bide our time and lull our victims into a false sense of security before taking our revenge.

 

I practiced some additional hobbling techniques as I stumped snaggle-legged down the hall with my hands full of coat, scarf, purse, paperwork, and a shoe. At the checkout, a woman with below-average intelligence (remember, average is 100 in America and something less than that in South Carolina) pushed paperwork at me across one of those little two-inch wide shelves that have sliding glass and no space to write…without pushing a pen with it. She was multitasking on the phone, and I got no response to my request for a pen. So I had to drop all my stuff on the floor and do a high G maneuver to locate a pen in the bottom of my purse.  Which was on the floor. You’d be surprised how used we all are to bending our right knee whenever we want to.

I asked a another nurse who was passing by to assist me (nice gait; I'd already learned to admire that in people), but, instead of giving me any direct help, she asked my name and perfunctorily mumbled for my husband in the waiting room. He doesn’t like to admit that he’s got a teensy hearing loss issue. Nurse Two, she of the very visible Harley tattoo,  gave the effort a full 2.5 seconds before marching past, saying she did not have time to spend searching for people's lost husbands. I can only conclude that everybody who comes to this particular medical office is of sound body and that there’s a real shortage of qualified nurses in our town. 

My darling husband, who usually does display above-average intelligence, suggested on the way home from the doctor’s office that he could maybe help me look for a pair of those black, 3 inch platform flip-flops he’s seen women wear. The high today is about thirty-five degrees here. It makes him nervous when the world plays All-Encompassing Ass Clown with me, and I think it interferes with his mental processing.

Yet, all’s well that ends well. I’m happy to report that, after putting the boot in the garage 24 hours a day (except when I was in the shower), after a few days my leg felt better.
 

So, help me with this.  Which would you do?

(a)    Return the boot right away, unused, just a few days after being given it, and ask the doctor’s helpful staff to arrange a reimbursement from the manufacturer…maybe limp into the office in hopes that the genius who signed me out would take pity on me…in full and deluded expectation that this doctor, or any other in this town, would ever be willing to treat me again.

(b)   Do something more creative with it.  Go ahead and suggest something. I dare you.

[image: nordstrom.com]

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