Depression, Deprivation, and Dysbiosis: Polyiatrogenesis in Multiple Chronic Illnesses

Making it Work: Everyday Life and Healthcare with Multiple Chronic Illnesses in Denmark

A growing concern in clinical literature with the "treatment burden" of living with multimorbidity raises questions about how we can study and produce knowledge on the impact of health care. In this article, we draw on ethnographic material from fieldwork among people with multimorbidity in Denmark and recent theorization on "values" in health care, to show how an ongoing "trying out" and ways of "just getting on with it" are enacted in illness trajectories marked by multimorbidity. Our findings point to the importance of attending to the subject positions that particular healthcare relations and encounters make possible.

The ambivalence of radiotherapy: Re-framing effects and their temporalities in treatment for gynaecological cancer

Within the biomedical paradigm, treatment effects are typically split into primary and secondary effects with temporality playing a key role in this separation. Yet, this kind of ordering of effects with some effects understood as happening on the 'side', secondary and temporary, does not fit with how they are experienced by many patients who undergo treatment for cancer. Drawing on empirical data from a research project that gathered narratives of women's experiences of radiotherapy for gynaecological cancer, we observe radiotherapeutic effects that are experienced as ambivalent and temporally diverse and as overlapping demands that the women endure and manage. We propose Derrida's concept of pharmakon as a relevant and useful analytic for understanding radiotherapy treatment, thus bringing into focus the ambivalent effects of radiotherapy - it is both therapeutic and toxic. Pharmakon, we argue, offers a way of disrupting the logics that govern current practices of therapeutic radiotherapy, and provides a way to re-negotiate the ordering and temporal understandings and practices of therapeutic efficacy, outcome and accountability of radiotherapy treatment - away from a temporal fragmentation of treatment effects and patients' bodily experiences to a focus on how best to support the whole patient in living with the ambivalent, temporally diverse and overlapping effects and demands of treatment.

Dementia, a Polypharmaceutical Phenomenon: The Intimate Combinations of Dementia Drugs in Brazil

It is commonplace to state that dementia is a complex condition. Such complexity involves the limits between pathological and normal aging, diagnosis with no simple organic causation, and the use of psychiatric medication that does not cure but generates hope to alleviate symptoms such as forgetfulness and delirium. Based on an ethnography of one year and a half (2017-2018) in a Brazilian metropolis, within a Public Geriatric center and the households of three families, I argue that dementia, more than a complex condition, is a generator of drug complexity. Following Stefan Ecks' reflections on multimorbidity and polyiatrogenesis and Karen Barad's understanding of intra-action, I discuss the polypharmacy present in most cases of dementia that I have known. Considering the complicated relations of medications with themselves and with time and places, I conclude that dementia should be seen a polypharmaceutical phenomenon.

Association Between Multiple Chronic Conditions and Depressive Symptoms Among Older Adults in China: Evidence From the China Health and Retirement Longitudinal Study (CHARLS)

Objectives: The purpose of this study was to explore the association between multiple chronic conditions (MCCs) and depressive symptoms among older adults in China. Methods: We used the fourth round of data from the China Health and Retirement Longitudinal Study, and included 9789 older adults aged 60 years old and above. Results: Compared with the older adults without chronic disease, older adults with MCCs and those with one chronic disease had a high risk of depression (MCCs: OR_-adjusted: 1.55, 95% CI: 1.37 to 1.75; one chronic disease: OR_-adjusted: 1.20, 95% CI: 1.05-1.37). In urban areas, the prevalence among older adults with MCCs was 2.01 times higher than that among older adults without chronic disease (OR_-adjusted: 2.01, 95% CI: 1.56-2.60), while it was 1.44 times higher in rural areas (OR_-adjusted:1.44, 95% CI: 1.25-1.65). Self-reported health, duration of sleep, social activities, and type of medical insurance were the influencing factors of depressive symptoms in older adults. Conclusion: This study contributed to enriching the research on the relationship between MCCs and depressive symptoms in older adults in China.

The emergence of multimorbidity as a matter of concern: a critical review

Multimorbidity is considered one of the greatest emerging challenges for contemporary health care systems. However, the meaning of the term ‘multimorbidity’ is not straightforward. Despite many attempts to clarify the definition and its measurement, the concept remains elusive. Still, academic interest in the study of multimorbidity has grown exponentially in the past ten years. In this paper, we trace the emergence of multimorbidity as a ‘matter of concern’ within health care research, exploring what has been called ‘the multimorbidity epidemic’ in the context of changing disease categories. We analyse how multimorbidity as a concept lays bare some major unresolved challenges within contemporary care services and summons up traditional primary care ideals of holistic, person-centred care. However, we argue that the current focus on the measurement and the identification of disease clusters falls short in contributing to better care for people who live with multiple long-term conditions now. Instead, we propose a novel understanding of ‘multimorbidity’ as an experience that manifests through people’s navigations of care infrastructures. To study this experience of multimorbidity, we discuss the potential of social science approaches that focus on ‘living well’ with illness.

"I Do Not Have to Hurt My Body Anymore": Reproductive Chronicity and Sterilization as Ambivalent Care in Rural North India

Drawing on 18 months of ethnographic fieldwork in rural Rajasthan, India, I examine women's narratives of chronic reproductive suffering and the practices they employed to relieve it. Cumulative effects of adverse and ordinary reproductive events and exhaustion from caregiving were often seen as reproductive suffering, while sterilization emerged as an act of care toward women's ever-weakening bodies. Sterilization has been an integral part of the often coercive, incentive- and target-driven population control program in India. Rural women, however, described sterilization not as a form of violence but as an act of care, despite its ambivalence. In the context of reproductive chronicity-a persistent reproductive suffering recurring alongside reproductive events, available care options, relations within which these options are located, and structural conditions that shape women's lives-care and suffering are intimately and ambiguously intertwined.

Beta Blockers can mask not only Hypoglycemia, but also Hypotension

Background:

Beta-adrenergic (β-AR) receptor blockers (BBs) are an essential class of drugs as they have numerous indications. On the other hand, they have numerous unwanted effects which decrease the compliance, adherence, and persistence of this very useful group of drugs.

Objective:

The paper aims to analyze the possibility that an unnoticed side effect may contribute to a less favorable pharmacologic profile of BBs, e.g., a diminished reaction to a sudden fall in BP.

Methods:

We searched two medical databases for abstracts and citations (Medline and SCOPUS). Moreover, we searched the internet for drug prescription leaflets (of the individual BBs).

Results:

Whichever cause of stress is considered, the somatic manifestations of stress will be (partially) masked if a patient takes BB. Stress–induced hypercatecholaminemia acts on β-AR of cardiomyocytes; it increases heart rate and contractility, effects suppressed by BBs. The answers of the organism to hypoglycemia and hypotension share the main mechanisms such as sympathetic nervous system activation and hypercatecholaminemia. Thus, there is a striking analogy: BBs can cover up symptoms of both hypoglycemia (which is widely known) and of hypotension (which is not recognized). It is widely known that BBs can cause hypotension. However, they can also complicate recovery by spoiling the defense mechanisms in hypotension as they interfere with the crucial compensatory reflex to increase blood pressure in hypotension.

Conclusion:

Beta blockers can cause hypotension, mask it, and make recovery more difficult. This is clinically important and deserves to be more investigated and probably to be stated as a warning.

The challenge of involving old patients with polypharmacy in their medication during hospitalization in a medical emergency department: An ethnographic study

Background

More than 70% of patients admitted to emergency departments (EDs) in Denmark are older patients with multimorbidity and polypharmacy vulnerable to adverse events and poor outcomes. Research suggests that patient involvement and shared decision-making (SDM) could optimize the treatment of older patients with polypharmacy. The patients become more aware of potential outcomes and, therefore, often tend to choose less medication. However, implementing SDM in clinical practice is challenging if it does not fit into existing workflows and healthcare systems.

Aim

The aim was to explore the determinants of patient involvement in decisions made in the ED about the patient’s medication.

Methods

The design was a qualitative ethnographic study. We observed forty-eight multidisciplinary healthcare professionals in two medical EDs focusing on medication processes and patient involvement in medication. Based on field notes, we developed a semi-structured interview guide. We conducted 20 semi-structured interviews with healthcare professionals to elaborate on the findings. Data were analyzed with thematic analyses.

Findings

We found five themes (determinants) which affected patient involvement in decisions about medicine in the ED: 1) blurred roles among multidisciplinary healthcare professionals, 2) older patients with polypharmacy increase complexity, 3) time pressure, 4) faulty IT- systems, and 5) the medicine list as a missed enabler of patient involvement.

Conclusion

There are several barriers to patient involvement in decisions about medicine in the ED and some facilitators. A tailored medication conversation guide based on the SDM methodology combined with the patient’s printed medicine list and well-functioning IT- systems can function as a boundary object, ensuring the treatment is optimized and aligned with the patient’s preferences and goals.

From Person to Life: An Anthropological Examination of Primary Health Care Approach to Depression in Rio de Janeiro

Mental illness approaches in public health have resulted in controversies around the adequacy of interpretative and therapeutic models. These controversies engage polarized debates amid understandings of mental illnesses either as brain disorders or as socioculturally determined entities. Aiming to investigate how mental health care is implemented in a Latin American metropolis, we conducted an ethnographic study of the approach to depression in a primary care unit in Rio de Janeiro between 2016 and 2017. "Life" emerged from our fieldwork as the main local category for understanding the experiences of patients with depressive symptoms and the work of reengagement performed by family physicians. With this investigation, we seek to provide insights into an approach to mental illness in primary health care that moves away from polarized interpretive frameworks and remains open to the singularities of patients' experiences of suffering.