On May 14, Dr. Keith Ablow, a Fox News contributor and practicing psychiatrist, posted comments on the Fox News website about the American Psychiatric Association and its current revision of the Diagnostic Statistical Manual. 

The DSM was created in 1952 to provide a complete and reliable source of diagnostic categories and descriptions of mental disorders. its formation was guided by two fundamental principles; that the diagnostic categories and criteria that define mental disorders, are supported by substantial scientific evidence, and that they are consistent with public health needs. the DSM is periodically revised to update diagnoses and their defining criteria as new knowledge is generated. the last revision to the DSM was in 1994.

In his article, Ablow made comments about the APA and DSM-V, which I believe are inaccurate and unsubstantiated by scientific evidence. Moreover, they are misleading to the public and potentially harmful in that by undermining the credibility of the psychiatric profession and its scientific underpinnings. they may even deter people in need from seeking treatment.

For this reason, I offer the following comments in response. I believe that I am qualified to do so as Professor and Chair of Psychiatry at Columbia University College of Physicians and Surgeons and the President Elect of the APA.

It is one thing to have a distressing and disabling psychiatric condition that affects one’s perception, cognition and emotions, and impairs quality of life, relationships and well-being.  but it is quite another level of tragedy when that condition goes undiagnosed, or when one is unable to get access to treatment because of stigma and shame or a lack of insurance coverage.  Relief from symptoms and recovery may be postponed or may never happen.  the consequences are not just inconvenience – as with any serious non-psychiatric medical condition, they are real, life-altering and potentially life-threatening.

For decades, the APA has worked diligently to provide definition in the environment of mental health through the development of the Diagnostic and Statistical Manual of Mental Disorders.  since DSM-III, each edition has provided evidence-based guidance in manual form for use by clinicians and researchers to diagnose and classify mental disorders so that patients in need can be effectively evaluated and gain access to treatments.

Since DSM-IV was released in 1994, there has been a wealth of new research and knowledge about the nature and frequency of mental disorders, how the brain functions and its neurobiology, and the lifelong influences of genes and environment on a person’s health and behavior.  Accordingly, the newest edition – DSM-V – will reflect that new body of knowledge.  And people who now suffer from a range of conditions will be the beneficiaries as they become increasingly likely to get an accurate diagnosis and access to treatment for it.

Many of the changes that are being proposed for this new edition were done to better characterize symptoms and behaviors of groups of people who are currently seeking clinical help but are less well-defined under the guidelines of the current DSM-IV edition.  the hope is that by more accurately defining disorders, diagnosis and clinical care will be improved and new research will be facilitated to help improve our understanding.  

The APA recognizes the importance not only of the document, but of the process for creating it and takes this responsibility with the utmost seriousness and as a sacred trust. Contrary to Ablow’s comments, the process for revision is not arbitrary and not politicized.  

For this revision, the APA recruited more than 160 of the top researchers and clinicians from around the world to be members of the DSM-V Task Force, Work Groups and Study Groups.  

These experts in neuroscience, biology, genetics, statistics, epidemiology, social and behavioral sciences, and public health were rigorously vetted for any conflict of interest using guidelines derived from other academic professional organizations and from the federal government itself and have worked assiduously for over five years to scour the scientific literature and determine whether any changes to existing DSM-4 diagnoses and additions were warranted.  they participated on a strictly voluntary basis and come from several medical and health care disciplines including psychiatry, psychology, pediatrics, nursing and social work.

The definition of mental illnesses may at times be a matter of debate – and they should be.  but the importance of mental illness and the need to recognize and diagnose it cannot be understated.  Without them, diagnostic approaches could vary widely.  the treatment of conditions would be uneven.  Payment for services would be difficult, to say the least.

For too long in human history, persons with mental illness were feared, persecuted or ignored. Stigma of mental illness in our society was pervasive. 

However, through biomedical research and enhancement of public awareness we have made great strides in the U.S. to establish a strong scientific basis for our understanding of human behavior and brain disorders that affect mental functions and bring them out of the shadows so that people can recognize symptoms and seek treatment. 

That is why the APA has gone to great lengths, and taken great care, from every angle, to produce a document that incorporates new knowledge to develop the latest guidelines that will benefit practitioners and patients alike.

Dr. Jeffrey Lieberman is the chairman of Department of Psychiatry at Columbia University College of Physicians and Surgeons, and director at the New York State Psychiatric Institute.

Sickness and death from ‘H5N1’ pale into insignificance when compared to many other infectious diseases that plague the world. But the dangers from new flu strains go well beyond those posed by this virus.

The bird flu known as ‘H5N1,’ which the world had largely forgotten about, suddenly sprang back into the news when recently the Food and Agriculture Organisation of the United Nations (FAO) issued a release warning of a ‘mutant strain’ of the virus that was spreading in Asia and beyond “with unpredictable risks to human health.”

Immediately afterwards, the World Health Organisation (WHO) issued a release of its own: “Based on available information, this evolution of the H5N1 virus poses no increased risk to public health. it is not considered unusual because influenza viruses are constantly evolving, especially in areas where they circulate regularly in poultry.”

The principal risk from the new mutant strain, designated H5N1-2.3.21, appears to be to poultry. The new virus is able to evade existing poultry vaccines against H5N1, and could therefore spread to other countries from China and Vietnam where it has been found.

As was the case with human flu vaccines whose composition needed to be reviewed annually, avian flu vaccines also needed to be regularly checked for their efficacy against viruses circulating in the field, the World Organisation for Animal Health (OIE) pointed out.

The OIE Reference Laboratory in Harbin, China, had developed a vaccine seed strain that experimentally protected poultry from the new virus. Registration and manufacture of a poultry vaccine with the new seed strain was in progress, it added in a press release.

Influenza virus are grouped into three types (A, B and C). Human pandemics have been caused by the type a viruses, which infect a wide range of birds and animals. The type a flu viruses are further categorised into subtypes based on two proteins they carry. The ‘H’ in the virus designation indicates the sort of haemagglutinin it possesses and the ‘N’ its neuraminidase subtype. While many subtypes are found in wild aquatic birds, only a few are able to infect humans.

When the highly pathogenic form of the H5N1 virus was first detected in dead geese in China’s Guangdong province in 1996, it didn’t attract much notice. But that changed the following year when it swept through Hong Kong’s live poultry markets and infected 18 people, a third of whom died. The administration in Hong Kong responded by culling all the poultry, which ended the outbreak.

The virus, however, continued to circulate in southern China. in the following years, it spread to other countries in the neighbourhood. But even in 2005, the virus was largely confined to South-East Asia. in May that year, the virus infected and killed a large number of migrating water birds that had gathered at the Qinghai Lake in western China.

“The deaths of swans and geese marked H5N1′s spread into Europe, India, and Africa,” remarked Robert G. Webster and Elena a. Govorkova of the Department of Infectious Diseases at the St. Jude Children’s Research Hospital in Memphis, U.S., in a paper published in the New England Journal of Medicine.

According to the FAO, “ since 2003, H5N1 has killed or forced the culling of more than 400 million domestic poultry and caused an estimated $20 billion of economic damage across the globe before it was eliminated from most of the 63 countries infected at its peak in 2006.” The virus was still firmly entrenched in six countries — Bangladesh, China, Egypt, India, Indonesia and Vietnam.

With outbreaks in poultry, the virus has from time to time jumped to humans too. since 2003, it has infected 565 people, according to data maintained by the WHO. more worrying is the fact that the resulting disease killed half of them.

However, an analysis published in Eurosurveillance recently by scientists at Germany’s Robert Koch Institute found that the human case-fatality rate from H5N1 infection varied from 28 per cent in Egypt to 87 per cent in Indonesia. even when adjusted for age, sex and time to hospitalisation, Egypt still had the lowest odds of people dying from the virus. Differences in the viral strains found in Egypt and Asia could not be ruled out as a factor, they said.

The scientists also noted that longer delay, from the onset of symptoms to hospitalisation and belonging to older age groups were associated with higher mortality.

Human sickness and death from H5N1 pale into insignificance when compared to many other infectious diseases that plague the world (malaria, for instance, is responsible for nearly a million deaths a year). But the worry has long been that this bird flu virus might take on a pandemic form and then sweep swiftly across the globe.

At present, the virus is not able to easily infect humans or pass from one individual to another. could the virus become better adapted to humans through mutation and exchanging genes with other flu viruses (a process known as reassortment)? If that does happen, would the H5N1′s lethality be reduced in the process?

The rationale for particular concern about a H5N1 pandemic was not its inevitability but its possible severe impact on human health, wrote J.S. Malik Peiris, a well-known virologist at the University of Hong Kong, and others in a paper published in 2007.

Such a pandemic, especially if it arose by the bird flu virus directly adapting to humans, rather than through genetic reassortment with a pre-existing human virus, could well be unusually virulent in humans. “thus, an H5N1 pandemic is an event of low probability but one of high human health impact,” they concluded.

When the flu pandemic of 2009 broke out, it was produced not by H5N1 but by a strain that made the leap from pigs to humans bearing a mix of human, swine and bird flu virus genes.

Pandemics have been caused by flu viruses that came over from animals, remarked Dr. Peiris when this correspondent met him last year. it was flu viruses from domestic livestock that were most likely to make the jump to humans.

Surveillance to monitor the viruses circulating in poultry and pigs was therefore essential. it was necessary to keep watch on whether such viruses were actively undergoing reassortment and if they possessed certain molecular markers, such as those for easily infecting humans, he added.

Pigs are of particular concern because they can become infected with both bird and human flu viruses, creating opportunities for gene swapping between viruses. The last three pandemics — and quite possibly the severe pandemic of 1918 too — were produced by flu strains that arose through such genetic reassortment.

Genes from the 2009 pandemic strain have been found in various reassortant viruses. a paper in the journal Science last year spoke of a novel virus that had been isolated from pigs in an abattoir in Hong Kong, which combined genes from the 2009 pandemic strain with those of a H1N2 virus.

Just recently, the U.S. Centers for Disease Control and Prevention reported a new H3N2 swine virus that had been able to infect children. The virus possessed a gene that had come from the 2009 pandemic strain.

In a paper earlier this year in the Proceedings of the National Academy of Sciences, a team of Chinese scientists showed in the laboratory that a mix of genes from the 2009 pandemic strain with those of the H9N2 bird flu virus could result in viruses that were more virulent than the parental forms. The H9N2 bird flu is found in poultry in many countries across Asia and so such reassortment could potentially occur naturally too.

The threat to human health from new flu viruses therefore go well beyond those posed by the H5N1 bird flu virus.

Flu viruses can evolve rapidly and scientists would like to find universal vaccines that can protect humans against all strains or at least a wide range of them. Current flu vaccines are able to target only closely related forms of a virus. As a result, the seasonal flu vaccine has to be modified annually depending on what viruses are circulating. As for pandemic strains, which are able to spread rapidly because few people have immunity to them, a vaccine can be mass manufactured only after the outbreak begins.

Recent research publications show that scientists are exploring a number of approaches for developing a universal flu vaccine. Francis S. Collins, director of the U.S. National Institutes of Health, was recently quoted as saying that he was “guardedly optimistic” that such a vaccine could be created within five years.

Withdrawal of Haitian football team was unavoidable, says Spencer

BY ALICIA DUNKLEY Senior staff reporter dunkleya@jamaicaobserver.com

Thursday, February 24, 2011

HEALTH Minister Rudyard Spencer says the circumstances that led to the withdrawal of the Haitian Under-17 football team from the CONCACAF championships on the weekend was “unavoidable and necessary in order to safeguard public health” and not out of any ill will towards Haiti.

According to Spencer, members of the contingent were screened by public health personnel — as required by international standards — on their arrival at the Sangster International Airport in Montego Bay on Friday. He said health officials were informed by Jamaica Football Federation doctors the following day that six members of the contingent were displaying symptoms of malaria.

According to Spencer, the individuals were taken to the Cornwall Regional but said all six left the hospital without the permission of the medical team. He said following dialogue between the various officials, five persons were admitted to the Falmouth Hospital, while one person refused to be admitted. three cases were subsequently confirmed and another eight persons identified as exhibiting fever symptoms.

The health minister said every effort was made to ensure that the contingent was taken care of, but noted that there was “resistance and lack of co-operation from members of the contingent and others who discharged themselves from the hospital before completion of their treatment”.

Spencer said the Ministry of Health made the recommendation to CONCACAF that the team be withdrawn from the competition in the interest of the well-being of the other teams involved. The majority of the Haitian team departed the island on February with the remainder following the day after.

Tuesday, Prime Minister Bruce Golding said the “misunderstanding” which sparked much anger in the Haitian community that viewed the team’s discharge as an affront was due in part to “a language challenge”.

Golding expressed “regret” over the extent to which the matter was “sensationalised and exaggerated in Haiti”, leading to protests in which the Caribbean Community flag was burnt. He said Foreign Affairs Minister Dr Kenneth Baugh had established contact with his peers in Haiti, noting that there was “far better understanding at that level”, leading to the arrival of a Haitian delegation in the island on Monday for further discussions.

Golding said that he had also had dialogue with Haitian President Rene Preval in which it was explained that Jamaica’s procedure for dealing with persons diagnosed with illnesses such as malaria was far different from the approach in Haiti.

He said there was no doubt in the president’s mind as to Jamaica’s support for that country, adding that it was “unfortunate that the misunderstanding arose”.

The family of one of about 2,300 patients who were notified that a San Pedro clinic unwittingly used contaminated needles to sedate patients contacted health officials Tuesday to report that the 76-year-old mother of two died from complications of hepatitis C.

County health officials sent notification letters to patients who were treated at the private medical clinic at 1412 W. Seventh St., advising them that they may have been exposed to infections such as hepatitis B, hepatitis C or, less likely, the virus that causes AIDS.

Those who received injections at the Advanced Pain Treatment Center between Jan. 16, 2006, and Aug. 18 of last year were advised to be tested. The letter was dated Jan. 4 and posted on the county’s website three days later.

“We recommend that you get tested for hepatitis B (HBV) and hepatitis C (HCV) as a precaution, even though the risk that you got infected at the time of your procedure is low,” wrote Dr. Laurene Mascola, chief of the Acute Communicable Disease Control Program at the Department of Public Health. “The test for HCV and HBV is a blood test. If you do test positive for any of these viruses, there are treatments available.”

The county agency was notified of a person with acute hepatitis C who had been treated at the clinic, but had no other risk factors for the disease, prompting the investigation that led to the notification letters.

Investigators identified “unsafe injection practices,” according to the department’s website.

Injections to sedate patients, not injections of medication, were thought to be at fault. A diagram on the agency’s website shows how a needle used to inject an infected patient could then contaminate a vial of saline. Even if clinicians used a clean needle to draw the saline for the next patient, the infection could be spread through the saline.

One of those letters was sent to the Torrance woman whose husband contacted county health officials Tuesday to report that his wife had been diagnosed with hepatitis C two years after receiving a series of injections for pain at the center.

She died of complications from the disease last may, according to the woman’s daughter, who spoke to City News Service on condition of anonymity.

The woman was referred to the clinic, established in 1999, by her orthopedic surgeon and began a series of treatments in April 2006. She had no known risk factors for hepatitis prior to being treated at the clinic, according to her family.

Upon receiving the Department of Public Health’s letter, the woman’s husband called the clinic and confirmed that his wife had, indeed, been a patient within the dates listed in the letter, according to the family. The husband then called DPH and was told that he was the first to report a fatality possibly linked to the tainted injections, the woman’s daughter said.

DPH officials said they could not immediately respond regarding her case, but did say that two cases of acute hepatitis among clinic patients – one HCV and one HBV – had been confirmed to date.

Testing for the potentially fatal blood-borne illnesses is important because many of those infected may not develop symptoms for a long time, according to medical professionals.

Though HIV infection is less likely, the department also recommended in the letter that patients be tested because it can spread in the same way as hepatitis, though “the spread of HIV by intravenous medications is not common.”

A clinic spokesman could not be reached for comment Tuesday afternoon, but told a television station earlier in the day that it is believed a nurse contaminated an IV line.

When asked if a nurse should know better than to cross-contaminate needles, Dr. Kamran Ghadimi responded, “Oh, absolutely, absolutely, yes, and she’s not a new nurse. She’s (been) practicing more than 20 years.”

According to a KCBS Channel 2/KCAL Channel 9 report, the nurse is still employed at the center, but no longer administering IVs.

The statement released by Public Health says the clinic “took immediate corrective action when notified of the issue by Public Health and has fully cooperated. The investigation is ongoing and Public Health will release more information when needed.”

HBV, HCV and HIV are required by law to be reported. Department officials sent separate notification letters to patients’ doctors, asking them to report any positive results within one business day.

A website has been set up with information about the alert at publichealth.lacounty.gov/acd/HepInfo.htm/.

The department plans to issue a full report on the investigation in June.

LOS ANGELES (AP) ? More than 5,270 cases of whooping cough have been reported in California’s growing epidemic, which has killed nine babies this year.

This week’s report from the California Department of Public Health finds that the highly contagious illness hasn’t infected this many in the state since 1955, when 4,949 cases were reported for the entire year.

Whooping cough is a cyclical illness that peaks in number of infections every five years. Symptoms are similar to the common cold, making it a challenge to diagnose. a persistent cough that lasts weeks is the tell-tale symptom of the illness, which is also known as pertussis.

The bacterial infection tends to peak during summer months, but reporting lags make it difficult to determine if the peak has passed.

Healthcare in Canada  Health Home >> Healthcare in Canada >> Health news Written by: JON WILLING, QMI Agency Aug. 13, 2010

OTTAWA – The sexual health centre is so hectic that Ottawa public health will ask city council for more money to hire additional staff to deal with a booming caseload of sexually transmitted infections.

“It’s pretty much no different from a family medical clinic,” program manager Andrew Hendriks said at the Clarence St. walk-in centre Thursday.

“It’s definitely packed.”

The centre saw 4,530 people pass through the doors between April and June, making it the highest tally of clients in one quarter since 2005.

Hendriks expects the number to rise even more this quarter.

AdHe said there has always been a demand in Ottawa for sexual health services but lately more people are seeking advice from city experts.

There has been a large increase in the number of reported cases of chlamydia, gonorrhea and syphilis in Ottawa, he said. For example, the number of reported cases of chlamydia — the most frequently reported of the three — jumped 52% between 2005 and 2009.

Dr. Vera Etches, the city’s associate medical officer of health, said clinics in other cities are seeing a similar trend.

“We know the rate of sexually transmitted infections are increasing,” Etches said, noting that there’s no simple answer to why the numbers are going up.

There are 80 city staff who work in the sexual health unit and 35 of them are dedicated to the clinic.

On a typical Thursday the clinic will see several dozen clients but Mondays are typically the busiest days for staff. It’s not uncommon for nurses to stay late to see people who have waited in line. Staff have developed a triage system so the most serious cases are handled quickly.

In addition to infection tests and treatment, the clinic provides pregnancy tests, emergency and affordable contraception, Hepatitis A and B vaccines, counselling and workshops.

Etches said ideally the program would like to hire eight more nurses and open a new sexual health centre.

But it’s not clear exactly how much money they would need.

The centre could help thousands more if it had added resources, she said.

Etches said staff are seeing potential clients walk away from the clinic when it’s busy.

Sometimes there will be a line already forming at the clinic door before it opens.

The most common client is between 15 and 29 years old, although nurses are seeing more men in their 30s and 40s with symptoms of syphilis.

Sexual health services run on a budget of about $1.5 million but it also generates some revenue from OHIP and contraception sales.

There are also satellite clinics and outreach services operated by the unit.

“Really, the next step is to expand,” Hendriks said.

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