Our mental illness epidemic has weighed heavily on my heart for years but I have never taken the time to write about it until I saw an Associated Press article about military suicides. I am profoundly saddened by the revelation that so many of our honorable servicemen and women who help sustain the niceties I take for granted would take their own lives in response to the tragedy and pain they endure in silence. This is a national calamity, and it appears we have failed them in some way. Were adequate and appropriate mental health resources available to them, and if so, did they ever feel the social freedom to avail themselves of these resources? Has our society established a standard whereby it is dishonorable and “weak” to seek support for mental strain? Have we been complicit in a tacit conspiracy to shroud their suffering in secrecy? There really is no debate because I know we are guilty of all. In the United States, “mental illness” is a dirty word. We marginalize, we mock, we demean people with mental disorders. But the truth is, at some point in time, nearly every one of us suffers from mental illness. It is as ubiquitous as the air we breathe.

Mental disorders aren’t merely schizophrenia, bipolar disorder or severe depression. In my view and experience, they are a continuum of emotions ranging from stress and mild anxiety to debilitating manic depression. In 2011, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimated our adult prevalence of any mental illness at 19.6 percent. SAMHSA defined any mental illness as “currently or at any time in the past year having had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorder.” I believe, 19.6 percent is a severe underestimate of our public health burden of mental illness. These data likely fail to capture common stories of mental illness residing outside our ill-informed stereotypes, limited definitions and stigmatizing misperceptions about mental illness. For example, statistics don’t fully capture the root causes of scores and scores of homicides in our inner cities, nor the genesis of our epidemic proportions of tension headaches, back pain, fatigue and exhaustion from chronic diseases like hypertension, obesity and heart disease. These chronic diseases are nearly all derived from living in a society that demands much for survival, achievement and status. I also know the data do not capture my own fleeting bouts of anxiety as a deadline approaches when I am ill-prepared, or the sadness and despair I feel after listening to patient after patient relate their stories about the shame and secrecy enveloping their HIV or hepatitis diagnoses. Luckily, I know how to cope with these emotional vicissitudes — a call to a friend to discuss my frustrations, a bike ride, a quick run or a 10-minute meditation in which I sit alone quietly to breathe slowly and deeply, to pray, to focus on gratitude. But too often, rather than turning to similar personal interventions, we subconsciously dismiss the source of our emotional strain — be it fear, anxiety or pain — and mollify these discomforts with swift and temporary solutions like polypharmacy, food, alcohol, tobacco or other substances. These make us feel whole again for an instant. Then the effects wane and the cycle repeats. To me this is all mental illness hushed by our public health definitions and societal perceptions of what it means to be mentally ill.

Our demand for a public health response to mental illness waxes and wanes in parallel with our fickle engagement in these isolated conversations following tragic events. The recent tragedy at Sandy Hook has the medical and public health communities once again openly discussing the moral imperative and urgency for intervention and more comprehensive approach to gun violence and mental illness. We know the two are inextricably linked. This time I hope the conversation will be sustained because we can no longer afford to hide behind the shame and stigma of an epidemic so pervasive as mental illness. As I read the article about suicide among our servicemen and thought about how taboo the subject is, I realized we are a nation of” stigmatizers.” We stigmatize many things. Stigma is born from community perception and judgment, and it is of our own doing. We are swift to label and marginalize the groups that most urgently require our empathy, understanding and compassion. I see the effects of our judgments in my infectious disease practice, and I also see it with mental disorders. In our society, seeking support for mental illness is a sign of weakness rather than a necessary gesture for self care and preservation. Recently I suggested to one of my most beloved friends that he seek counseling as a mechanism to resolve a few difficult and emotionally painful issues. His response, somewhat in jest, was basically, “I am a man. I don’t do that.” His opinion is widely held, particularly among men, and sadly is likely deeply ingrained in our military personnel. Perpetuating the notion that to seek counseling signifies weakness is among our gravest societal mistakes. It is contributing to our public health crisis. As I learned during my studies with Dr. Jim Gordon at the Center for Mind Body Medicine, counseling assumes many forms and is a powerful and severely underutilized wellness intervention!

These days, we talk incessantly about living well and achieving life balance, yet we wear masks to hide our pain. No matter who you are, true wellness can never be achieved behind these and without facing our pain and stressors. The revelation of the loss of life from suicide among members of our military should assist us in maintaining a renewed urgency to devise a public health approach to mental disorders. Their decisions to end life rather than stay with us and engage are a poignant reminder about our urgent need to raise awareness, discuss these issues aloud and proactively change the national perception about mental disorders. To our honorable men and women who took their own lives, thank you for your service and may you rest in peace. For your sakes, I hope we can learn from the lesson you are teaching us and commit to do better and do whatever is necessary to be mentally well.

For more by Dr. Lisa Fitzpatrick, click here.

For more on mental health, click here.

Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.

A colleague just called me to advise him about treatment options for treating a patient he has diagnosed with a “superbug.” Superbugs are ordinary bacteria that no longer respond to our usual antibiotic armamentarium. They are drug-resistant. The conversation led to a discussion about the NIH superbug debacle this past summer. In August, there was public ire directed at NIH over “lack of transparency” about the deadly drug-resistant bacteria. As I told him, it is an ire that is misplaced and misguided. In an editorial response to the situation, a citizen wrote, “NIH had an ethical obligation to inform the public about this dangerous threat to the public health.” If this were the barometer by which people gauged their willingness for hospital admission, most would elect to convalesce at home. The NIH is no guiltier than hundreds of top-notch hospitals across the nation that don’t alert the community to similar struggles with containment of increasing prevalence of drug-resistant bacteria. The accusing finger should not be specifically leveraged against NIH but against community members and health-care providers across the U.S.

The death toll from the NIH superbug was six but in 2011, the CDC published dataattributing 98,987 deaths nationwide to these health-care-acquired infections. The truth is, for over a decade the CDC, health educators and a variety of other health mavens have been warning the public about the urgent need for behavior change in antibiotic prescription and usage, but this information has fallen on deaf ears. Antibiotic overuse by patients and overprescription by health-care providers are largely to blame for the emergence of drug-resistant bacteria. Therefore, lest the community continue to express outrage about the NIH’s lack of transparency, may I suggest an examination of the primary behaviors that have led to this urgent public health crisis.

First, health information about appropriate antibiotic usage is largely ignored by the community. Patients often feel entitled to antibiotics, and demand them regardless of whether or not they are medically warranted. During my residency in the mid-90s, while moonlighting in an urgent care center, I remember an interaction with a patient who arrived knowing exactly what she wanted. She told me she had come to get a prescription for amoxicillin because she could feel a cold coming on. She wanted to take the antibiotics pre-emptively to thwart the cold or, in her words, “knock it out” before it was full-blown. I told her antibiotics were for bacterial infections and because colds and flu are caused by viruses, the antibiotics were not warranted. She continued her argument, relating that all of her illnesses start in the same manner; she would later develop colored phlegm, signifying a bacterial infection; and the only thing that would help was taking an antibiotic at first symptoms. When I refused to relent, she told me about the other doctors who had prescribed the antibiotic in the past, and said that if I didn’t give her a prescription she would simply return and get the prescription from another doctor. I am sure she did.

Second, many health-care providers across the U.S. prescribe broad-spectrum antibiotics aimlessly and carelessly. Antibiotics have become a safety net as evidence of tangible health-care delivery. Patients want doctors to “do something.” In a society now accustomed to pharmaceutical remedies for every malady, when faced with an elusive or unknown diagnosis, an antibiotic prescription mollifies both the patient and the doctor. This cavalier approach is now pervasive in the health-care industry, and has helped create a culture of widespread availability and accessibility to antibiotics, which are the largest contributors to emergence of drug-resistant bacteria. When a patient first arrives with an unknown illness, understandably a provider may elect to cover as many bacteria as possible with an antibiotic, i.e., broad-spectrum. The problem arises when health-care providers are not diligent and thoughtful about the scientific and laboratory evidence supporting or refuting their decision to continue this broad coverage. It’s a perfect storm for bacteria crafty enough to reconfigure themselves to ignore and evade the threat of broad spectrum antibiotics. This behavior has perpetuated the continued emergence of multi-drug-resistant bacteria like the superbug at NIH and many hospitals across the U.S. I was once consulted by another doctor to see a patient who appeared to have an infection. Upon review of the information, I discerned the patient did not have an infection and recommended antibiotic discontinuation. The doctor thanked me for my consult and discharged the patient on antibiotics “just in case” the patient had an undetectable infection.

The emergence of multi-drug-resistant bacteria is a challenge that will be with us for years to come. The solution demands a strategic, thoughtful and collaborative team approach. Scientists can contribute to the team by developing new antibiotic agents to treat drug-resistant organisms or “superbugs,” and I am confident they will. However, once these agents are available, what will prevent us from witnessing emergence of resistant “superbugs” to new, more powerful antibiotics if we don’t initiate behavior change in antibiotic overuse and prescribing patterns? Behavior change is never a popular remedy to a health crisis, but in this case it’s vital. Health-care providers and the community members have a critical role to play in in addressing this public health crisis. Each can consider adopting one of more of the following actions:

1. Review the CDC health information on appropriate antibiotic use. The vast majority of upper respiratory infections result from viruses like influenza. Viruses do not respond to antibiotics and are therefore not necessary. Community members can refrain from demanding antibiotics. Keep an open mind when engaging your health-care provider about an unknown illness or infection. Antibiotics may not be the solution, and you may leave the office with only health advice rather than a prescription. Maintain close — and truthful — communication with your health-care provider about changes in your symptoms. Health-care providers can trust clinical judgment to discern appropriateness of antibiotics and devise practical ways to educate patients about responsible antibiotic use.

• Limit personal antibiotic usage. Unfinished antibiotics often remain in the home. Never use an old antibiotic to treat a new infection or borrow leftover antibiotics from friends and relatives. Always consult your health-care provider to determine the need for a new prescription.
• Learn about where to dispose of unused antibiotics by going to the DEA website. This prevents unwanted antibiotics from contaminating the general water and food supply.
• Wash your hands. Handwashing remains the single best and most effective public health intervention for interrupting the spread of bacteria and viruses. Wash hands regularly with soap and warm water.

Finally, reduced community demands and provider prescription will be impactful, but the solution will likely also require quality control programs, restriction and evaluation of antibiotics prescription by infectious diseases experts, particularly in hospital settings. This strategy will undoubtedly be unpopular and controversial, and may invite resistance from health-care providers who shun the oversight. However, the status quo is unacceptable and demands action. Anything less will mean waiting for the next sensational story about the wrath of a new superbug. Only then the death toll will likely be much, much higher.

For more by Dr. Lisa Fitzpatrick, click here.

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I was sitting in a café writing an editorial about HIV testing as I waited for my breakfast. I noticed a young man sitting behind me but didn’t give him a thought. My number was called so I got up to retrieve my food. When I returned to the table the young man asked if I was a doctor. I asked how he knew and he realized he had been caught reading the document on my computer. I was glad he did. His curiosity led to an epiphany that exacerbated my professional restlessness about addressing the HIV epidemic. We are still failing to educate the community about HIV. This 29 year old with two years of college from an esteemed university engaged me in a conversation that helped me realize despite our marketing and educational efforts thus far, our messages are not getting through to the people who need them most. Right there in the café, he spoke so openly about his HIV knowledge I could not let the opportunity pass to probe his notions about the disease. I sat and listened for nearly 30 minutes in complete awe… and sadness. He talked without almost no prompting as if he had been waiting for someone to come along and listen to everything he knew about HIV. Occasionally I would jot a few words on my computer to capture his thoughts and remind me of the lessons he was bestowing upon me. He told me:

He used to visit friends in a group house and would sometimes be invited to sleep over on the sofa. He later learned that one of the residents was HIV-positive. From that day forward, he would stay in the house but was “nervous” about sleeping on the couch when she was in the house and couldn’t sleep through the night. He knew he couldn’t get HIV from the couch but the presence of an HIV-positive person in the home made him uncomfortable. One of his friends told him if you use same shower as someone who is HIV-positive you should wash the tub with bleach before taking a shower. He has concerns about contracting HIV from a toilet seat because if an HIV-positive person has used it before him, the germs might still be in the toilet and if the water splashes up and contacts his skin and he could get infected. He has a friend who thought he may have been exposed to HIV so he drank a cup of bleach.

He believes people with HIV should be segregated from the rest of society and “should have their own groups” but mostly for their own good because it would make them feel more comfortable. He added this is also a good thing for them since they probably don’t have anything else to live for. He made a distinction between HIV and AIDS and said there was no treatment for “people with full blown AIDS. That would be a miracle”. He added if treatment was available for AIDS then people would take it and just keep on doing what they are doing. (It was the first truth in all of his ranting). He continued, in a hospital setting, “HIV-positive people should all be segregated on their own hospital ward.” He talked about how you can always tell who has AIDS because they have lost a lot of weight and their “brain is not functioning right”. He wanted to know if you could catch it from sharing a “smoke.” I asked if he would eat off my fork if I was positive. He said no and launched into a diatribe about how certain African communities eat from a communal dish with their hands and how this is probably contributing to the spread of HIV. I asked if he would allow an HIV-positive relative to live in his house. He said no.

He told me about stories he had read on the internet. There is a man in Kenya who has the cure for HIV but no one knows about him except rich people. Magic Johnson learned about this man and flew to Kenya, paid the man $1 million and now has been cured of HIV. He also thinks the government is about to eradicate antibiotic availability the impact of which he said is people with gonorrhea will no longer be able to be treated.

I asked if he felt his friends and family shared these beliefs. He answered emphatically, “Absolutely.” My heart sank repeatedly throughout the conversation but it was a teachable moment and I realized the challenge was also a tremendous opportunity. The epidemic is over 30 years old. The science has progressed but for some our thinking, perceptions and awareness have not. We must be more aggressive about ensuring community awareness about basic HIV information. I seized the moment to continue my discussion with the young man in the café that day and highlighted important information everyone must know about HIV in 2012:

AIDS is no longer a death sentence. No one has to die of AIDS anymore. The treatment for HIV infection prevents AIDS and leads most people with AIDS to a full recovery. Sometimes it takes a bit longer for the immune system to recover in people with AIDS but the treatment works well, even in people with “full blown” AIDS. Many patients who learned they were positive many years ago but never sought treatment have come into my office on death’s door because they were afraid to hear they had AIDS or because they didn’t realize that AIDS can now be treated. Last month one of my patients who was diagnosed with AIDS in 2009 came for a follow up visit. Her HIV is so well controlled on medication we talked about her HIV for less than five minutes. We spent the remainder of the visit trying to devise a practical strategy for her to lose the 76 pounds she regained when she started to feel better. Because the treatment is excellent with few side effects for most people, it no longer matters if someone with HIV infection has AIDS. And certainly no one has to die from it.

HIV is not spread by casual contact. HIV is completely preventable. A person can not become infected with HIV by hugging, touching, kissing, sharing a cigarette, sitting on the same furniture, using the same bathroom or eating and drinking from the same utensils. A person gets infected with HIV by sharing blood, semen, vaginal and anal fluid. Anal and vaginal sex are the most common ways to contract or transmit HIV. In fact, having anal sex without a condom is the highest risk sex act for contracting HIV. This is important because many heterosexual people engage in anal sex but may not realize the risk associated with HIV transmission. I recently delivered a seminar for a group of teenagers who were shocked to learn anal sex is a risk factor. The information was a wakeup call for them since some routinely engaged in anal sex to prevent pregnancy or to preserve virginity. The risk of contracting HIV through oral sex is very small and unlikely unless the giver or receiver suffers from bloody gum disease. The risk of HIV transmission also increases in people with sexually transmitted infections like herpes, syphilis, untreated gonorrhea and Chlamydia.

HIV does not have “a look.” In 2009 at a World AIDS day program, I invited several HIV-positive persons to serve as panelists for a community audience. The audience was unaware of each panel member’s HIV status but I asked them to guess which person was HIV-positive. A few people made selections based on appearances but overall the audience was surprised to learn the truth. The panelists included heterosexual men and women with ages ranging from 20-60. You cannot look at a person and suspect his or her HIV status, especially people who take their HIV medication faithfully. Magic Johnson, despite his wealth, is a wonderful example of what how medication for HIV is effective and allows people to live a long healthy life. His recent appearance in a PBS documentary illustrates his healthy appearance and his continued need for medication. Many of my patients are low to middle income but those who faithfully take their HIV medication look just as healthy as Magic Johnson.

HIV transmission is preventable. Many people know HIV infection can be prevented by using condoms consistently, abstaining from sexual activity or maintaining one HIV-negative sexual partner. Each of these is critical to eliminating the spread of HIV. However, preventing HIV begins with knowing whether or not you have HIV. The Centers for Disease Control and Prevention estimates that 1 in 5 people do not know his or her HIV status. Because HIV is now a treatable condition like diabetes or high cholesterol, getting tested for HIV is life-saving. Furthermore, many people are not aware that treatment for HIV prevents the spread of HIV. This is because HIV transmission will be drastically reduced if an HIV-positive person takes medication everyday. Because the medication stops HIV from reproducing in the body, if the amount of HIV in the bloodstream and tissues is low or “undetectable,” an HIV-positive person is much less likely to spread the virus to another person. For many years we have known HIV medications can reduce transmission because medication given to an HIV-positive mother was shown to prevent transmission to her baby. Similarly, a more recent research study among heterosexual people revealed HIV-infected people whose virus was controlled by medication were 96% less likely to transmit HIV to their HIV-negative partners. These are tremendous advancements in the treatment and prevention of HIV. But we will only see the benefit of these advancements if everyone gets tested, infection is identified and treated by a medical provider.

My epiphany in the café was that despite our marketing and often cursory and isolated educational efforts to publicize HIV-related information, we are ineffective. As I wrapped up my conversation with the young man, he was appreciative and eager to know more. We discussed the need for continued and specific HIV education throughout the community. We also talked briefly about solutions which we agreed largely will require combined efforts across the country such as community members and people with high visibility- he suggested influential hip-hop artists- engaging in sustained conversations about HIV or healthcare providers beginning to offer HIV testing just as routinely as they offer a blood sugar test to look for diabetes. These efforts will help reduce the shame and embarrassment associated with being HIV-positive, a byproduct of which is open and free discussion which invites solutions rather than misinformation and judgment. If we really want to address the epidemic, we need to analyze reasons our messages are not getting through to the people who need them most. Then we must make the commitment to boldly move forward to broach uncomfortable discussions — no matter how difficult, sensitive and offensive our messages may be because these conversations will ultimately save lives.