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The Health Hazards of Insurance
May/June 2007
by Bruce Fellman
When Claire Smith (not her real name) was rushed to Yale–New Haven Hospital after suffering a severe heart attack, doctors there performed an immediate angioplasty. “We were afraid she would die,” says cardiologist Harlan Krumholz.
Smith recovered. But when Krumholz, the Harold M. Hines Jr. Professor of Medicine and Epidemiology and Public Health, told her she would need several medications to help prevent a second heart attack, Smith said that she simply couldn’t afford the drugs. Her insurance wouldn’t pay for them. “This really hit home,” says Krumholz. “We can do everything right medically, but if the system isn’t set up to provide support afterwards, patients will not have the same chance for recovery.”
While public debate has focused on the 15 percent of the U.S. population without health insurance, Krumholz recently turned his attention to the underinsured. Nearly two-thirds of Americans with health insurance report having difficulties paying their medical bills. “When it comes to determining how well someone will be doing a year after having a heart attack,” he says, “we found that a patient’s financial circumstances are one of the most important risk factors.”
The study, reported in the March 14 issue of the Journal of the American Medical Association, was the first to ask people directly about financial barriers to proper care. Krumholz and his colleagues followed 2,498 heart attack patients for a year after hospitalization. In this group, 18.1 percent reported financial barriers to health care, and 12.9 percent reported difficulties paying for medication. More than two-thirds of the people in each of these categories had some form of health insurance. (Close to half were covered by Medicare or Medicaid.)
The costs of inadequate care can be significant, says Krumholz. “In the groups reporting financial barriers, we found significantly more instances of angina [chest pain], a poorer quality of life, and a higher risk of rehospitalization.”
The consequences were most noticeable among people who couldn’t afford the drugs, which Krumholz estimated can cost $200 per month or more. “This study puts into clear focus the ‘two Americas,’” he says. “As doctors—and as a society—we’ve got to address more than just clinical factors to ensure good health care and outcomes.”
Hitchhiking across Australia
by Rhea Hirshman
In 1935, when beetles were destroying the sugar cane crop in northeastern Australia, farmers fought back by importing beetle-eating cane toads from Central and South America. The enormous amphibians—a Bufo marinus can weigh more than two pounds—failed to control the beetles. But the toads became a permanent part of the continent’s northeastern landscape.
“It’s the quintessential invasion story,” says David Skelly, an ecology professor at Yale’s environment school. Skelly, Mark Urban '06PhD, and Australian colleagues Richard Shine and Ben Phillips have built a computer model showing that the cane toad may eventually double its current range. (Their work appeared online this March in the Proceedings of the Royal Society B: Biological Sciences.) Since the toad packs poison in its glands and skin, this is bad news for many native snakes and mammals that feed on amphibians, Skelly notes.
The toads, prolific breeders that can travel rapidly by hitchhiking on trains and cars, are comfortable in humandesigned environments. They now reside in many ponds and gardens. Adds Shine, “There is no reason to think that [the toads' process of] adaptation has stopped. They are superb invaders.”
Grief, by the book
by Carole Bass ’83, ’97MSL
Everyone knows about the five stages of loss, popularized by Elisabeth Kubler-Ross to describe the experience of terminal illness and then tweaked to address the grieving process. But who knew that these stages were mere theory, untested by empirical research?
Until now. Yale Department of Psychiatry researcher Paul Maciejewski and a team from Harvard—headed by Maciejewski’s wife, Holly Prigerson—worked with 233 people (average age, 63) taking part in the Yale Bereavement Study, a project that examined all aspects of the grieving process in a sample of southwestern Connecticut residents. All had suffered the recent death of a family member or loved one from natural causes. The researchers interviewed participants, and administered grief and depression assessment tests, at 6 months, 11 months, and 20 months after the death.
The results, reported in the February 21 issue of the Journal of the American Medical Association, offer both confirmation of the five-stage theory and a couple of surprising contradictions. The first contradiction: although Kubler-Ross held that denial dominates the first stage of grieving, with acceptance coming last, the researchers found acceptance starting early and prevailing throughout.
The second surprise was that the strongest “negative” emotion is yearning for the loved one—not depression, as Kubler-Ross and others believed. “It’s really the absence and missing” that are the dominant elements of grief, says Maciejewski, an assistant professor of psychiatry. “You live with someone, you interact with them every day, and all of a sudden they’re gone. This yearning taps into the social component of human beings, the way we make bonds with each other.”
The part of the study that confirmed classical grief theory was surprising in its own way. Except for the acceptance twist, the other stages—denial, yearning, anger, and depression—peaked and faded in “exactly the sequence of the stage theory.” When his team saw the data, their reaction was “Wow,” says Maciejewski. “It seemed so improbable that the sequence would work out exactly as predicted.”
Next, Maciejewski plans to develop criteria for a proposed new diagnosis of “prolonged grief disorder.” The current study provides, he says, “a better understanding of what normal bereavement is. These feelings are most intense in the first six months, and then they decline.”
He cautions, however, that because the study excluded deaths from causes such as car crashes and suicide, normal responses to that kind of loss might be different. Indeed, Thomas Frantz, a professor of counseling, school, and educational psychology at the State University of New York-Buffalo, notes that because Maciejewski’s subjects were mostly older people who had lost their spouses, the results are “almost irrelevant” for parents mourning the death of a child.
“It takes at least a year and a half to two years for a normal, healthy person to work through the loss of a child,” says Frantz.
This is your brain on Prozac
by Elizabeth Svoboda '03
Prozac, Zoloft, and similar antidepressants are seen
almost as miracle drugs in our culture—even though scientists have had
only a murky understanding of how they work. Ron Duman, a neurobiologist at the
Yale medical school, has now demonstrated one of the ways in which these drugs
achieve their effects: by spurring the growth of new brain cells.
It’s long been known that Prozac and its relatives
slow the pace at which serotonin, one of the neurotransmitters that help nerve
cells communicate with one another, is taken up and inactivated (hence the name
“selective serotonin reuptake inhibitors,” or SSRIs). But to Duman, this
function seemed insufficient to explain how the drugs elevate mood. “It takes
weeks before patients respond to these drugs, so we knew there had to be more
sustained mechanisms occurring,” he says. Several years ago, he found that
SSRIs increase the expression of a protein called vascular endothelial growth factor
(VEGF) in the brain. He also discovered that they encourage neurons to form in
the brain’s hippocampus, a region believed to play an important role in mood
disorders.
In the March 13 issue of Proceedings of the
National Academy of Sciences, Duman described his study showing that higher VEGF levels are
directly responsible for the growth of new hippocampal cells. He had
administered SSRIs to rats for 14 days; as predicted, their VEGF levels went up
and they showed neuron growth in the hippocampus. He also dosed a second group
of rats both with SSRIs and a chemical known to inhibit VEGF’s function. This
group did not grow any new brain cells. Significantly, rats in the first group
also showed behavioral changes—trying to escape more often and drinking
more sugar water—that indicate an antidepressant effect. And rats
receiving only VEGF behaved like the rats receiving SSRIs.
Because VEGF affects many tissues in the body, Duman
is skeptical that it can realistically be used as an antidepressant for humans.
“It might have some tendency to make cancer cells proliferate, for instance,”
he says. Still, he hopes his VEGF finding will help shed light on the question
of who is likely to develop depression and why. “Whenever we find an important
molecule like this, the genetic studies kick in,” Duman says. “We can now start
looking for mutations related to that molecule that could lead to increased
vulnerability to the disease.”  |
