Believing in Treatments That Don't Work

NYT - David H. Newman, MD

In the early throes of a heart attack, caused by an abruptly clotted artery, the stunned heart often beats quickly and forcefully. For decades doctors have administered “beta-blockers” as a remedy, to reduce consumption of limited oxygen supplies by calming and slowing the straining heart. Giving these drugs in the early stages of a heart attack represents elegant medical ideology.

But it doesn’t work.

Studies show that the early administration of beta-blockers to heart attack victims does not save lives, and occasionally causes dangerous heart failure. While two studies support the use of beta-blockers after heart attack, there are 26 studies that found no survival benefit to administering beta-blockers early on. Moreover, in 2005, the largest, best study of the drugs showed that beta-blockers in the vulnerable, early hours of heart attacks did not save lives, but did cause a definite increase in heart failure.

Remarkably, the medical community has continued to strongly recommend immediate beta-blocker treatment. Why? Because according to the theory of the straining heart, the treatment makes sense. It should work, even though it doesn’t. Ideology trumps evidence.

The practice of medicine contains countless examples of elegant medical theories that belie the best available evidence.

• Recent press reports detailing the dangers of cough syrup for children have noted that cough syrup doesn’t work. True: No cough remedies have ever been proven better than a placebo, either for adults or children. Yet their use is common.
• Patients with ear infections are more likely to be harmed by antibiotics than helped. While the pills may cause a small decrease in symptoms (for which ear drops work better), the infections typically recede within days regardless of treatment. The same is true for bronchitis, sinusitis, and sore throats. Unnecessary antibiotics are still given to more than one in seven Americans each year for these conditions alone, at a cost of more than $2 billion and tens of thousands of serious adverse medication effects requiring treatment.
• Back surgeries to relieve pain are, in the majority of cases, no better than nonsurgical treatment. Yet doctors perform 600,000 of these surgeries each year, at a cost of over $20 billion.
• More than a half million Americans per year undergo arthroscopic surgery to correct osteoarthritis of the knee, at a cost of $3 billion. Despite this, studies show the surgery to be no better than sham knee surgery, in which surgeons “pretend” to do surgery while the patient is under light anesthesia. It is also no better than much cheaper, and much less invasive, physical therapy.

Treatment based on ideology is alluring. Surgeries to repair the knee should work. A syrup to reduce cough should help. Calming the straining heart should save lives. But the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.

The critical question that looms for health care reform is whether patients, doctors and experts are prepared to set aside ideology in the face of data. Can we abide by the evidence when it tells us that antibiotics don’t clear ear infections or help strep throats? Can we stop asking for, and writing, these prescriptions? Can we stop performing, and asking for, knee and back surgeries? Can we handle what the evidence reveals? Are we ready for the truth?

The administration’s plan for reform includes identifying health care measures that work, and those that don’t. To place evidence above ideology, researchers and analysts must be trained in critical analysis, have no conflicts of interest and be a diverse group.

Perhaps most importantly, we as doctors and patients must be open to evidence. Pills and surgery are potent symbols of healing power, but our faith in these symbols has often blinded us to truths. Somewhere along the line, theory trumped reality. Administering a medicine or performing a surgery became more important than its effect.

During the first week of 2009, in what may be a hopeful sign, hospital administrators around the country received a short, unceremonious e-mail from the Centers for Medicare and Medicaid Services. The e-mail explained that, due to recent evidence, immediate beta-blocker treatment will be retired as a government indicator of quality care, beginning April 1, 2009. After years of advocacy that cemented immediate beta-blockers in the treatment protocols of virtually every hospital in the country, the agency has demonstrated that minds can be changed.

The much more important question for health care reform is, can ours?

Do You Know What Your Doctor Is Talking About?

NYT - Pauline W. Chen, M.D

Lately when I see patients nodding their heads at the end of a visit, as if in agreement with the therapeutic plan, I can’t help but remember Jack.

Jack (not his real name) had barely entered middle age when I met him, a hospital patient who suffered from diabetes, high blood pressure, vascular disease and kidney failure. I spent about a week caring for him, covering temporarily for a colleague who was away, and I quickly learned from the nurses that Jack was a well-known figure on the ward. A former professional athlete and a gifted raconteur, Jack never tired of recounting his past glories to anyone who would listen, even if his audience happened to be the one person in the hospital who had no idea of how his sport was played. Over the course of that week, I heard about his last-minute triumphs against opposing teams, the coaches and fans who followed his every move, and the perks, financial and otherwise, that came with being part of a winning team. I remember Jack’s eyes lighting up during these stories; his arms would wave wildly as if he were about to catch a ball, and his mouth would open so wide with laughter that I could see the fillings glittering within.

But it was always difficult, as I watched Jack come alive, to reconcile those glorious stories with the man sitting on the edge of the bed. His muscles had wasted away so much that I could see the graceful undulations of the long bones of his arms, count the ribs on his chest, and observe the tendons flexing on the back of his hand.

It was also hard to miss Jack’s legs, or what remained of them. On the left, his leg had been amputated below the knee; on the right, he had a small stump that ended at what would have been mid-thigh.

Despite his professional successes, Jack had done little to care for himself over the years. He bounced in and out of the hospital, spending progressively less time at home and more time as an inpatient. He ignored his high blood pressure for years, irreversibly damaging his heart and kidneys. He neglected to control his blood sugar and developed diabetic foot ulcers that grew larger and never healed, leaving his doctors with no options other than to amputate at progressively higher levels.

Some of the doctors and nurses thought Jack took such poor care of himself because he had taken to drugs. Others believed that the gifted athlete refused to acknowledge that his body could ever betray him. But I have always wondered if it was because we never explained his condition and the importance of self-care in a way that rang true to him.

Each day that I saw Jack, I examined and dressed an open wound at the base of one of his stumps. The stump had become infected at home but improved in the hospital with regular dressing changes and antibiotics. From time to time, I would look at Jack as I explained, in "laymen’s terms,” what I was doing with gauze and the antibiotics. He would nod quietly, but his eyes would go blank.

Once I persisted in asking him about how he managed his diabetes at home. I did not ask him as someone might ask a storyteller, an athlete, a once acclaimed celebrity of sorts; rather, I was the doctor, pressed for time, speaking to one of many patients. Jack smiled sheepishly in response, then with a grand gesture waved away both inquisition and inquisitor.

Jack was later discharged home, and a few months later, I asked my colleague how he had fared.

“He died,” my colleague answered. “He went home and didn’t take his antibiotics. His diabetes got out of control, and he ended up dying in the I.C.U. from a disseminated infection.”

Memories of Jack played over again in my mind one recent day as I saw patients. I worried about these new patients because as much as I’d like to believe that Jack was an exception, recent studies have shown that almost half of all Americans have trouble obtaining, understanding or acting on information that is important to their health. They suffer from what researchers now term “limited health literacy.”

In a system where much of patient care happens at home and where patients and their families shoulder a large part of the health care responsibilities, limited health literacy can have devastating consequences. Patients with limited health literacy tend to be in poorer health, partake less frequently of preventive health measures and screening, and become hospitalized more frequently, resulting in an estimated annual cost of $50 billion to $73 billion.

A recent study put the cost in even starker terms: elderly patients with limited health literacy are almost twice as likely to die.

Jack, I now suspect, had limited health literacy. He didn’t comprehend the severity and complexity of his diseases and couldn’t care for himself, in part, because no health care professional had ever spoken to him in a way that he could process. And his pride prevented him from asking for help.

Several health care groups and government agencies have initiated national campaigns — like Speak Up and Healthy People 2010 — to address health literacy. These efforts encourage patients to take a more active role in educating themselves about their health and, not surprisingly, focus on ways to improve the interaction between patients and doctors.

I spoke recently to Dr. Rebecca L. Sudore, assistant professor of medicine at the University of California, San Francisco, and lead author on the landmark study that linked limited health literacy to higher mortality rates. I asked her about the patient-doctor relationship and health literacy.

“Over the years,” she said, “the health care system has gone from a paternalistic, doctor-centered model to one that is patient-centered, with shared decision-making on every level. I think it’s great, but that really places high literacy demands on patients. We expect them to go home with diabetes or congestive heart failure or an organ transplant and just take care of themselves.“

Dr. Sudore spoke at length about the expectations and assumptions in the patient-doctor relationship. “There’s a lot of power differential, and patients have learned to be deferential. Those patients who are disenfranchised and who have been treated poorly in the medical system don’t have the confidence to ask for help or explanations. There’s a sense of shame around this, and patients won’t always tell you that they don’t understand. That’s just way too embarrassing.”

“For doctors,” she added, “there just isn’t any time to sit down and make sure your patient understands. Doctors have these external pressures. They have 15 to 20 minute interactions in the clinic; and on the wards they are running from patient to patient.”

And, she said, many of us will be touched by limited health literacy at some point in our lives. “We will be caretakers, or even patients ourselves, who have to interact with the health care environment. And research has shown that even those who are educated can still have low health literacy.”

Dr. Sudore went on to suggest ways in which doctors and patients might address health literacy. “One thing we tell clinicians to do is to ’teach back’ or ’teach to goal.’ A clinician might say, ’I’ve just said a lot of things and I want to make sure I’ve explained things clearly to you. Can you explain things back to me, so I know you understand?’ This discussion creates a kind of a shared understanding. The doctor may not have the time, but these questions can bring up red flags that can be discussed during a follow-up appointment.”

For patients, Dr. Sudore recommended taking the initiative to tell the doctor how much is understood. “You should go back to the doctor and say, ’What I hear you saying is this. Did I get that right?’ Or, ’I’m leaving the hospital. You just gave me this new drug, but I’m still supposed to take all my other medications. Is that right?’ ”

Dr. Sudore reflected for a moment on the season. “I’ve been doing my taxes, and I keep thinking that it would be great if someone wrote these forms at the sixth grade level, in a more straightforward way. All of us just prefer information that is easier to understand.”

“And in something as charged as health care,” she said, “people who understand can get more.”

Sleeping Pill Use Grows as Economy Keeps People Up at Night

LA Times

Lost jobs and lost careers. Promising businesses in shambles. The college acceptance letter returned to its envelope. This is how President Obama recently described the effect of the tanking economy on ordinary Americans -- and the stresses keeping them up at night.
Sleeplessness is a problem even in good times. One in 10 U.S. adults routinely has trouble getting to sleep or staying asleep, and 3 in 10 experience occasional sleeplessness, federal statistics show.

But these are definitely not good times. More than 1 in 4 -- 27% of Americans -- say anxieties about personal finances, the economy or a job loss kept them awake in the previous month, according to a new poll by the National Sleep Foundation.
If that isn't enough evidence of our increasingly sleep-deprived state, consider this: Since September, audiences of such after-prime-time network shows as "Late Night With Conan O'Brien" have risen. No wonder the collective experience of "sleepless nights" found its way into a presidential address.

As Americans struggle for a good night's rest, they are looking for help from a pill. Prescriptions for sleeping medications topped 56 million in 2008 -- a record, according to the research firm IMS Health, up 54% from 2004.

Those numbers could grow. With an economic turnaround not expected before late 2009, some specialists are predicting another record year for sleeping pill use.

"The first stress symptom people experience is insomnia," said Dr. Gregg D. Jacobs, an insomnia specialist at the University of Massachusetts Medical Center in Worcester. "The size of the sleeping pill market can only go up because of the economy and stress."

But sleep medications are not without risk: next-day drowsiness is the most common among a list of adverse reactions that include dependence and memory loss. As more people take the drugs, the number of people experiencing problems is likely to rise.

For those reasons, some sleep disorder experts say, it may be time we learned to fall asleep on our own.

Effects on the brain

Sleep is a complex physiological process connected to such environmental factors as light and temperature. As night falls and temperatures drop, chemicals in the brain begin to slow the activity of neurons responsible for attention and wakefulness -- and drowsiness sets in.

The two largest classes of sleeping pills enhance the activity of one of these brain chemicals, a neurotransmitter called gamma-aminobutyric acid, or GABA. This neurotransmitter is an imperfect drug target because it performs multiple functions in the brain. Depending on the receptors involved, GABA may promote sleep, decrease anxiety or relax muscles.

Benzodiazepines, an older class of sleep medicines that includes Valium, enhance the broad range of the neurotransmitter's effects -- one reason why benzodiazepines are also used to treat panic attacks. But benzodiazepines lost their popularity as sleep medications in the 1990s after reports of side effects, including drug dependence. England removed the sleeping pill Halcion from the market in 1991 because the medication was associated with depression and memory loss. Although Halcion is still available by prescription in the U.S., it carries a strong warning.

The newer GABA-enhancing pills are known as the Z drugs, so-called because the drugs have the letter "z" in their generic names. Now the most popular prescription sleep medications, the class includes Ambien (zolpidem), Sonata (zaleplon) and Lunesta (eszopiclone). Ambien and Sonata act on the receptor connected to sleep more selectively than other GABA-enhancing drugs The Z drugs carry a smaller risk of dependence than benzodiazepines, a key reason for their popularity. However, the U.S. Drug Enforcement Administration classifies both the benzodiazepines and the Z drugs as scheduled drugs, meaning they all have some risk of dependence.

Another of the newer pills, Rozerem (ramelteon), does not target GABA. It acts on the melatonin receptors in the brain, which are thought to help regulate sleep-wake cycles. It is the only prescription sleeping pill that does not carry a risk of dependence. But doctors tend to think it is not as effective as competing pills.

The perceived safety advantages of the newer drugs over the benzodiazepines -- and aggressive consumer advertising -- have spurred prescription growth.

During 2007 and 2006, drug manufacturers Sanofi-Aventis (the maker of Ambien), Sepracor (maker of Lunesta) and Takada (maker of Rozerem) spent an average of $11.8 million a week to advertise sleep medications, according to the market research firm TNS Media Intelligence. Total prescriptions for sleep medications increased 10% and 15% respectively in those years, according to IMS Health.

Drug makers have since slashed ad spending in response to competition from lower-cost, generic versions of Ambien, 50% in 2008 alone, but the demand for sleep help continues to rise. Those cheaper pills are now driving most of the prescription growth.

The Z drugs reduce the average time it takes to fall asleep by 18 minutes and increase total sleep time by 28 minutes compared with a placebo, according to a National Institutes of Health-funded analysis published in 2005. Some sleep specialists believe the improvement is minimal, but other sleep experts contend the extra sleep makes a difference when accumulated over several nights.

Rozerem was approved in 2005 and not included in the analysis, which was performed by the Agency for Healthcare Research and Quality. The agency noted it used published studies to get its results, so the real-world performance of the drugs may be worse.

Researchers are continuing to search for better insomnia drugs. Swiss drug maker Actelion is conducting a late-stage clinical trial of almorexant, a drug that blocks the activity of a peptide called orexin, which is believed to have a role in wakefulness. In a previous study, 147 subjects taking almorexant fell asleep 18 minutes faster -- no better than what is seen with existing pills. But researchers found no association between almorexant and "next day" effects.

Side effects

Sleep specialists say the pills can be useful to help break a cycle of sleeplessness, or to overcome jet lag. But some doctors are concerned that the heavy prescribing contributes to a false impression that the medications are perfectly safe. In fact, many sleep medications can cause what doctors call a "next-day effect" - a pill-induced drowsiness that spills into the next day.

The Food and Drug Administration two years ago required strong warnings on 13 sleep medications, including Ambien and Lunesta, because rare but bizarre behaviors have been linked to the pills, including cases of sleep-walking, sleep-driving and sleep-eating. Some people have set small fires while trying to cook, their minds in a fog induced by sleeping pills. In the morning, they don't remember the incidents.

Researchers aren't sure why the pills cause odd reactions. One theory has it that the people reporting bizarre behaviors are neither fully asleep nor awake. They have no memory of their nocturnal forays because the pills can have a mild amnesiac effect, blocking the formation of memories.

In January, a 51-year-old Wisconsin electrician was found frozen to death after sleep-walking outdoors in subzero temperatures. Sawyer County coroner Dr. John Ryan said the man had been drinking and the sleep aid Ambien was detected in his bloodstream. Alcohol is known to increase the risk of side effects from sleeping pills, he noted.

"It's my strong suspicion that's what did it," Ryan said.

Drug makers say patient safety is a priority and the labels on their products display information about side effects, including advice to avoid alcohol when taking the pills.

Dr. Michael Thorpy, a sleep specialist at Montefiore Medical Center in New York and a consultant who commented at the request of Ambien maker Sanofi-Aventis, said strange sleep behaviors can occur naturally and it's wrong to blame the pills in all cases. Some complaints of memory loss might be due to sleep, which also has an amnesiac effect; it's one reason why people forget waking in the middle of the night, he said.

But the risk of side effects and dependence isn't the only potential downside to a prescription for sleep medications.

Dr. David Fassler, a clinical professor of psychiatry at the University of Vermont, said some doctors may be prescribing medications instead of treating the underlying cause of sleeplessness, such as depression or anxiety.

"Trouble sleeping can be a sign of multiple disorders," he said in an e-mail. "It can also be a response to stress or conflict at home, in school or at work. People need a careful assessment to figure out that's actually going on. Effective and appropriate treatment really depends on an accurate diagnosis."

Younger pill takers

Of particular concern to some sleep specialists is the age at which people are turning to sleeping pills.

Adults under age 45 are fast replacing the elderly as the prime market for sleeping pills, according to the research firm Thomson Reuters. The most dramatic growth was seen among college-age adults, whose use of prescription sleep aids nearly tripled to 1,524 users per 100,000 in 2006 from 599 users per 100,000 in 1998.

"If they start to depend on sleeping pills in their late teens and early 20s, they are setting themselves up for a pattern of sleeping pill use," said Jacobs of the University of Massachusetts Medical Center's sleep clinic. Like many sleep specialists, he recommends patients first try behavioral therapy to help them overcome the negative thoughts keeping them awake. Jacobs also has a company that markets a drug-free insomnia treatment program.

Many college students probably use the pills to manage sleep habits that are often out of sync with class schedules.

"Going to bed at 3 in the morning and sleeping until noon on weekends is not unreasonable at that age," said researcher James K. Walsh, a spokesman for the National Sleep Foundation, who manages the sleep clinic at St. Luke's Hospital in St. Louis. Students with an early-morning class might use medications to help them get to bed earlier the night before, he said.

But college students are not immune to the economic stresses that are taking a toll on older adults. Scripps College sophomore Jane Logenbaugh Sherwood said she takes a pill to lull her to sleep when worries about her career prospects keep her awake. "I'm in college so I can go out into the world and find a job," she said. "I'm stressed out about the rest of my life."

The Psychology of Stress

MSNBC

In the economic tailspin of the late 2000s, loss is part of life. Workers are losing their jobs, employers are losing their businesses, and as credit becomes more and more scarce, everyone is losing confidence. What's more, entrepreneurs are grappling with a sense that they've lost control of critical factors that could determine their futures. Those psychological hurdles are perhaps the biggest challenges facing today's business owners; after all, it was probably that shining confidence and ability to innovate that got you started in the first place, right?

"So much of it has nothing to do with you," says Tarek Tay, 36, co-owner and managing partner of Atlanta's Zaya Restaurant, which launched strong in February 2008, boomed through the summer--and then saw business drop 30 percent in September. Although well-reviewed, it has operated in the red since, even with $1.2 million in 2008 sales. "If your food isn't good, you can improve the quality," he says. "If service is the problem, you can train your staff. But if the problem is that no one's going out to eat because of the economy, what can you do?"

As he and his partners fund Zaya with profits from the New Orleans restaurants they also own, Tay works tirelessly on cost cutting and marketing. "It makes me feel like I'm not giving up," he says. "When I'm out there working and I end up with a busy night, then I get to experience some sense of return. If you sit at home, your worries just fester in your mind."

In other words, he takes control of what he can. In fact, studies have found that a sense of personal control--the belief that you set your destiny--is one of several characteristics shared by happy people. These days, gaining that sense of control might seem like a tall order. But even when the world is hurtling toward an uncertain future, there's one thing that's always and entirely up to you: your perspective on that world. And if you're an entrepreneur in an economy on the brink, your perspective could be getting a little loopy.

Actually, it's called cognitive distortion, says Edward Trieber, a clinical psychologist, an attorney and the managing director of Harris, Rothenberg International LLC, which provides integrated

solutions, executive coaching, web development and more. Cognitive distortion can cause people under undue stress to discount positive events, seeing only the negative. They also might lose their long-term perspective, focusing exclusively on the immediate fires they're called upon to douse, or perceive even minor events as major catastrophes. As of late, Trieber's company has been helping businesses cope with the stress of economic uncertainty. According to the American Psychological Association, nearly half of Americans (47 percent) report that 2008 brought increased stress--with money and the economy topping worry lists--while 30 percent say their stress is extreme.

Think Straight
Your first stop on the cognitive thrill ride: a network of people to talk to, says Trieber--and not for the warm fuzzies. Friends and family can point out when your doomsday scenarios are getting a little too biblical for your own good; they'll also remind you that you're more than your work. "When people define themselves by their business," says Trieber, "they might conclude, 'If my business isn't doing well, then I'm not doing well.'"

That's a precarious position in a volatile economy. But for husband and wife team Eric Haggard, 47, and Kimberly Rock, 42, whose home is security against their Torrington, Connecticut, business lines of credit, work and life really are one and the same. Rock recalls the period before she and Haggard launched their online retail business RealMemories.com as one of the most stressful times of her life.

Today, she realizes the danger of losing her home wasn't as real as it felt then. "But fear isn't always rational," says Rock, whose site, which provides archival-quality custom framing for digital photography, launched with $225,000 and brought in $100,000 in 2008 sales. "For one week, I wallowed in the what-ifs. And it did me absolutely no good."

Instead, she and Haggard wrote their way through the fear, synthesizing a long- and short-term plan of action. Relief was immediate. "When you put everything on paper," Rock says, "it's not floating around in your head as this nebulous, insurmountable set of fears."

Writing slows your thoughts enough to clarify those that aren't serving you, says Trieber, while a plan gives you perspective. "If you thought that for the rest of your life, you'd be working in this business environment, things would seem very grim," he says. "But when you see how things could be in two or five years, it's easier to tolerate what's happening now."

Haggard and Rock, who also own the million-dollar business PulpProducts.com, used to check sales figures daily--sometimes after particularly feverish economic newscasts. Nixing that nervous habit, they now look at sales monthly and quarterly. "With an online retail business, your mood can swing daily," Haggard says. "When orders are up, you're up. When orders are down, you're down. We made a conscious effort to stay positive by looking at the big picture."

Physical Reaction
At Seattle's Hyde Evans Design, a small interior design firm with $1.5 million in annual billings, the phones practically forecast the Dow. "There's a direct correlation between the amount of calls we get and news about the economy," says founder Barbara Hyde Evans, 55. "When the markets drop, clients start calling to say, 'Do you think we really need to do such and such? Maybe we could put that off.'"

As Hyde Evans' high-end residential projects slowed through 2008, she had to lay off an employee and shift to what they're calling "holiday hours." Another employee left to become an in-house designer at Starbucks, which seemed to offer more stability. "The stress was getting to the point where I sometimes felt physically ill," she says.

And she's not alone. Three quarters of people experience symptoms like headaches or upset stomachs because of stress, according to the APA, which recommends exercise to manage it. For many, that's tough. According to a national survey from Amway Global, 38 percent of Americans say getting enough exercise is their biggest challenge to healthy living. Not for Hyde Evans. Once weekly, she and her staff members arrive at the office early, move the conference table aside and take a yoga class led by an instructor. "Two of our clients want to join us," she says. "It hasn't happened yet, but we joke that we truly are a full-service design firm."

She's even found a silver lining around the dreary cloud of slow business: time for all the things--organizing the office, advertising aggressively--that she was too busy for in the past. "It's an opportunity in that sense," she says.

"Extreme inflection points always create opportunity," Trieber says. "Yes, you may have lost something, but there could be something to gain. Look at your situation and say, 'What positives, if any, are available to me now?'"

The Other Side
This past year, former advertising executive Tami Quinn, 43, and her Pulling Down The Moon co-founder and co-director Beth Heller, 41, watched the SBA's lending volume drop nearly 30 percent. So this year, the founders of the integrative care for fertility center, which reports 2008 sales of $1.2 million, have had to shelve aspirations for opening a fifth location.

"We've had so many challenges that could have threatened our business," says Quinn, whose center works with doctors to incorporate holistic modalities, like yoga, acupuncture, massage and stress management techniques, into medical fertility treatments. "Every time something like that happens, we turn to each other and say, 'OK, what's the opportunity here?'"

In this case, Quinn and Heller decided that if it's not possible to open a fifth location, they would pour their energy into making sure their four locations were that much more extraordinary. "In yoga, we say you can only go so far into the forest before you start coming out of it," she says. "Using that line of reasoning, you can see that this economy will only be bad for so long before it starts to get better."

So keep moving forward. We'll see you at the clearing up ahead.

Basic Steps Toward Work-Life Balance

Forbes

Among the many things the average professional deals with daily: getting ahead at work; helping the kids with their homework; driving the school carpool; spending quality time with their significant other; caring for elderly parents; dealing with chores in the home; trying to get in just a few minutes to catch up with friends.

Life can feel like a constant battle between our professional and personal lives, especially now, with the economic distress making our lives more challenging than ever in so many ways. Before you beat yourself up about not being able to get everything done, consider these tips for achieving a better balance between your work and the rest of your life this year.

First, prioritize. "If you want balance--and not everybody does--you have to force yourself to edit yourself personally and professionally," says Jody Miller, founder of the executive staffing firm Business Talent Group.

Consider all the things competing for your time and decide what will stay and what will go. Perhaps you're on the holiday party committee at work. That's something you can skip next year. What about the three nonprofit organizations you belong to? Select one that means the most and focus your time on it instead of giving scattered attention to all three.

"Focus on the things that are important to you, and don't do the extraneous stuff," says Miller. "It's a discipline that doesn't come too naturally to most of us."

Sometimes gaining a few extra hours in your day makes all the difference. Find out if your firm has policies that would allow you telecommuting or flexible hours. In this economy it's hard to imagine asking for additional benefits, but imagine how much more you could get done if you telecommuted one day a week. By eliminating commuting and getting ready for work, you could likely get about three hours back.

When discussing this option with the boss, approach it from a position of strength. Consider saying, "I like my job, and feel I am an asset. I see a place here for me in the future. I'd like to talk about ways I can make my work here as productive as possible. I'm in a not-so-unique situation of caring for my elderly parents (or whatever your particular situation is), and working from home once or twice a week would give me much-needed extra time. I believe I'd be able to give you better work, since I'd be less distracted."

You might be surprised to find your boss sympathetic--particularly if you're a top performer--because he or she is in a similar situation. In this economic climate, when employers can't give raises, they may be willing to offer other benefits. They want to treat their best employees well, so that when the market turns around those employees don't immediately leave for another company.

To Work Your Brain, Work Your Body

Chicago Tribune

Problem:I lost my car keys. What kind of training will make my brain work better?
Solution: Brain-boosting software programs are a booming business. And studies show that both computer exercises and old-fashioned mental activities—reading or crafting—can affect memory.

But the best thing you can do for your brain is to move your body. "If I had to pick between fitness training and brain training, I'd go with fitness," said Sam Wang, an associate professor of neuroscience and molecular biology at Princeton University. So far, he said, exercise has been shown to have an effect several times larger than computer-brain exercise.
But Wang noted that "fitness training only lasts as long as the benefit to your cardiovascular system." Brain exercise, on the other hand, "might last longer."

Wang said he would never shell out $3,995 for the bike, which is available in the U.S. only in South Florida, but it could be a double workout for the brain.
What he would really like to see is a computer that works only if he's moving on an exercise bike or treadmill.

Teens' Emotions May Affect Diabetes Control

Reuters

Teenagers with type 1 diabetes may have a tougher time managing their blood sugar on days when they are feeling angry or down, a new study suggests.

The findings, published in the Annals of Behavioral Medicine, suggest that emotions may affect teens' blood sugar control by making them less confident in their ability to manage their diabetes.

For the study, Katherine T. Fortenberry and colleagues at the University of Utah in Salt Lake City recruited 62 subjects between 11- and 16-years old with type 1 diabetes, an autoummunne disorder that res caused by an abnormal immune system attack on the body's insulin-producing cells. People with the disease have to take daily insulin injections, closely monitor their blood sugar levels and be careful about their diets to avoid sugar highs and lows.

Teens in the study kept a daily diary for two weeks, detailing their mood and confidence in their ability to manage their diabetes.

In general, Fortenberry's group found, the teenagers' blood sugar levels were more likely to be near-normal on days when they were happy or excited.

On days when they were sad or angry, their sugar levels tended to be higher, the researchers report in the Annals of Behavioral Medicine.

The teenagers' self-confidence in their diabetes control seemed to explain the link, Fortenberry's team found.

They note that teenagers who stay positive in the face of managing the disease may be more likely to take all the steps they need to keep their blood sugar in check. Helping teenagers to manage their emotions, the researchers write, may have "important implications" for their lifelong diabetes control.

Can One Drug Cure Addiction to Another?

John Cloud - Time

Americans are fond of the idea that they can keep from doing "bad" drugs by taking "good" ones instead. The heroin/methadone model has actually been institutionalized: you can go to government-funded clinics to get methadone as "maintenance treatment" for heroin addiction — since both drugs bind to the same brain receptors. Experimental types in the '60s believed that LSD was a wonder drug that could cure alcoholism. The same claim was made during the '80s for a drug that was, at the time, perfectly legal and even used by a few psychotherapists: MDMA, a chemical now better known as ecstasy.

For decades, the holy grail in the search for good drugs to supplant bad ones has been a pill that might replace nicotine, which is powerfully addictive and — especially when delivered through cigarette smoke — incredibly dangerous. And in 2006, the holy grail seemed to have been found. Pfizer released Chantix, a drug the Food and Drug Administration (FDA) approved in May of that year to help smokers quit. Since then, doctors have written more than 6 million prescriptions for Chantix. It's no magic bullet. Chantix fails with most people who take it; fewer than half of those on the drug actually stop smoking. But going cold turkey works for fewer than one in 10 smokers, so in comparison Chantix is considered a great advance.

Now a new paper in the journal Biological Psychiatry says the drug, which carries the generic name varenicline, has also helped a group of regular drinkers consume less alcohol. So could varenicline be a new anti-addiction panacea?

The new study, which was conducted at Yale, is small but promising. Twenty regular drinkers (defined as those who consume at least one drink per day and, at least once a week, three or more drinks in a single sitting) took varenicline or a placebo daily for a week before showing up for the experiment. None was dependent on alcohol, and none had tested positive for illicit drugs. At around 3 p.m. on the day of the experiment, all were asked to drink a cocktail of their choosing. Afterward, if they wanted, they could have more cocktails. The 10 who had taken varenicline drank an average of just .5 drinks after their first cocktail. By contrast, the 10 who were taking placebos consumed 2.6 drinks. Eight people in the varenicline group declined all further drinks after their first, compared with only three in the control group. (It's worth noting that the varenicline takers also smoked far fewer cigarettes than the placebo group during the 14-hour the experiment. Everyone who participated was a regular smoker.)

But there's a downside. Varenicline reduces cravings by binding to and blocking nicotine receptors in the brain. The drug affects how your brain releases dopamine, the key neurotransmitter that plies the brain's reward pathways and lays down roots of addiction. Typically, your brain gets a shot of dopamine every time you have a drink or — if you're a regular smoker — every time you drag on a cigarette. (Or, for that matter, every time you do anything pleasurable, like win at a craps table or snort a bump of coke or crystal meth.)

But by acting on dopamine receptors, varenicline also may change the way some people experience joy. Last year, the writer Derek de Koff (who was a longtime smoker and also — full disclosure — an acquaintance of mine) wrote a harrowing New York magazine account of his experience with varenicline. He experienced awful hallucinations while taking the drug — he wrote about speaking to a man in a bar who turned out to be a shadow cast by a potted plant. De Koff also became despondent. "I wondered whether [varenicline] was zapping my brain's pleasure-delivery system to such a degree that not only did I find no reward in cigarettes, but I also found no reward in socializing, exercising, writing, or any of my usual self-stimulating tricks," he wrote. De Koff thought about throwing himself in front of a bus or launching his head into his computer.

He isn't alone. Last year, the FDA issued an alert noting that "serious neuropsychiatric symptoms have occurred in patients taking [varenicline] ... These symptoms include changes in behavior, agitation, depressed mood, suicidal ideation, and attempted and completed suicide." The deaths of a musician and a TV executive have been linked to use of the drug.

But varenicline is only the most recent anti-drinking drug to have negative side effects. Some of these side effects are considered to be the treatment itself: disulfirman, also known as Antabuse, which has been used with alcoholics for many years, causes hypotension and vomiting when a person has alcohol. Naltrexone, which blocks opioid receptors in the brain, is another option for chronic drinkers, but it can cause nausea.

Similarly, varenicline is no cure-all. In another new study, this one published in the Journal of General Internal Medicine, a team led by Seattle researcher Jennifer McClure found that a group of smokers with a previous history of depression experienced irritability, anxiety and depressive symptoms slightly more frequently while trying to quit with varenicline than smokers with no prior history of depression.

The study did find that among the 1,117 patients who took varenicline, 43% were cigarette-free after three months. But the balance of evidence so far suggests that while trying to quit one drug by taking another may be useful, you don't get something for nothing. Swallowing a pill is better than poisoning your lungs with smoke or pickling your liver with bourbon, but you shouldn't fool yourself into thinking the pill can't harm you.

"Something's happening out there. People are losing sleep," says National Sleep Foundation board member Woodie Kessel. "There needs to be a public health message, because sleep is not something you can compromise on — it has consequences. It is as important as diet and exercise."

According to the 2009 Sleep in America poll by the National Sleep Foundation, out today, more than a quarter (27%) of Americans are losing sleep over financial worries.

The number of people reporting poor sleep has almost doubled since 2001, says Kessel, a Bethesda, Md., pediatrician. Survey takers who reported sleep troubles because of economic concerns were two times more likely to report sleeping less than six hours on a typical workday, and they drove while drowsy more often than those who reported sleeping better.

People who slept poorly were also almost twice as likely to eat high-sugar and high-carbohydrate foods, and they smoked or used tobacco more often than better sleepers.

Sleep specialists say the survey results mirror patient concerns in their medical practices lately. "We've been seeing this clinically for months, a very sharp increase in insomnia due to stress," says Joseph Ojile, CEO and founder of Clayton Sleep Institute in St. Louis.

People with existing sleep problems as well as new patients are lining up for help, other medical experts say. "I can say I've probably seen a 10% to 15% increase in phone calls from our existing patients and a 10% increase in new-patient calls," says Carolyn D'Ambrosio, director of the Center for Sleep Medicine at Tufts Medical Center in Boston.

Ojile says losing slumber time goes deeper than just feeling tired. "It likely affects you at some basal metabolic level (energy put out while the body is at rest). Research indicates people eat more poorly when they sleep less, that hormone changes occur, and some studies suggest those who sleep less weigh more."

An increase in sleep drug sales also points to increasing struggles with insomnia. According to data from IMS Health, a health care information company, 56,287,000 prescriptions were dispensed last year for sleep medications, such as Ambien and Lunesta, a 7% rise since 2007.

But the sales burst is not necessarily a bad sign, Ojile says. "If it's part of a broader overall health package that includes a healthy diet and exercise, then sometimes medication can help get someone over a difficult time. But if people are turning to medication in lieu of healthier sleep patterns, that's not OK."