Blue Collar Scientist

Researchers at Johns Hopkins and elsewhere published a study yesterday in Annals of Allergy, Asthma & Immunology¹ which establishes that asthma is associated with higher levels of suicidal thoughts with attempted suicides.

Doesn’t surprise me one bit.

The Flying Trilobite recently had a posting about asthma, a response to some google traffic that was coming his way, and over there I outed myself as an asthmatic from a very young age. When I was a kid, I had asthma severe enough to result in airway remodeling - in my case decidedly not good remodeling, though there is legitimate scientific debate whether remodeling in general is beneficial or deleterious - and today I walk around with significantly reduced lung capacity, compared to what I should have for my height and body weight, or whatever the norms are based on.

The reason that I’m not surprised to see asthma associated with suicidal thought and attempts is manyfold.

First, not being able to breathe properly is frightening and extremely painful, especially to the muscles that are used to breath - the shoulders, chest, and back in particular. Educated patients understand that few people die of asthma - but we are also taught that those that do often die of suffocation over a period of days or weeks of continuous and gradually worsening asphyxiation. We also understand that normal use of our life-saving medications can lead to refractory asthma - which is usually especially severe and frequently results in death; if you can walk out of the ICU, you consider yourself lucky.

Faced with an uncertain future, I know that I would feel a lot more comfortable about my existence if I knew that palliative care was available in the event that I faced a severe, probably terminal bout of asthma. But such palliative care is denied to asthma patients. We must tough it out, and that’s that. I can easily imagine that after a week or two of continuous symptoms, a perfectly rational asthmatic who cannot get any pain relief might be in the mood to take what the medical establishment would consider to be a few too many sleeping pills. I’ve never been down that road myself, but I’ve thought quite a bit about end of life care, knowing that if I don’t die of an accident or other sudden cause, I’m likely to die of asthma and its complications, and I’m unhappy in every way with what I know of how medicine treats the dying asthmatic.

The researchers sum up what I’ve just said in this way:

“Researchers have speculated that the relationship between asthma and suicidal behaviors is possibly because of ensuing mood and anxiety that results from disability and discomfort associated with asthma, which can be a lifelong disease,” they note. “Individuals might have frequent thoughts of death with increasing severity solely because they have a potentially life-threatening illness.”

To which my response is, no shit.

Technically, my evidence is anecdotal and personal; this hypothesis should be tested properly. But it rings true and I don’t consider it a high-risk experiment.

Second, much of my society does not accept asthma as a legitimate condition. Through the 1950’s, asthma was considered a psychosomatic condition - a disease that was entirely in the sufferer’s head. Until the mid 1960’s, treatment for asthma was dispensed by psychiatrists and psychologists in this manner²:

At that time, psychoanalytic theories described the aetiology of asthma as psychological, with treatment often primarily involving psychoanalysis and other ‘talking cures’. As the asthmatic wheeze was interpreted as the child’s suppressed cry for his or her mother, psychoanalysts viewed the treatment of depression as especially important for individuals with asthma.

Cry for my mother, my ass.

Asthma is now proven to be a real disease. In fact, it is an immune disease, a consequence of a too-active immune system. Remember this the next time a quack medical cure purveyor tries to sell you something that “boosts the immune system” - I have a boosted immune system, and trust me, you don’t want one. Asthma is an immune response in the bronchial airways, leading to constriction of those airways, excess mucous production, and is topped off with inflammation. All three of these leave less room for air to enter and exit the lungs.

Despite the objectively measurable physiologic symptoms, and despite the ability to induce asthma in anyone using a Methacholine challenge or similar test, the condition was considered until recently³ to be all in the patient’s head. Although the medical establishment changed its mind and recognized the condition as a real disease - and kudos to the medical establishment for responding to evidence, I’m not trying to say they were negligent in any way - the rest of our society has been slow to follow in the time since.

Despite medical evidence that prompt use of a rescue inhaler is necessary to save the lives of asthmatics, despite federal laws that protect the rights of asthmatics, and despite state laws mandating that schools allow asthmatic children to carry inhalers, there are still people who are too short-sighted to notice, or care, about asthmatics.

This school used to have an outright ban on medication, until I and others pointed out the illegality of the situation to an asthma activist organization. In response to massive pressure, the school changed the policy, and now if you fill out a form, the school says you can, they guess, have your medicine, if it is absolutely necessary that, you know, the student continue to live, or something. See also here,

Here is a school (pdf) that illegally requires the inhaler to be kept in the nurses office, and explicitly calls the use of the inhaler a “privilege” - at this school, the right to continue living is suddenly no longer a right. They also give broad, draconian powers to teachers who think the inhaler isn’t needed to deny its use to students. Here’s a hint for you - school teachers are not qualified to make medical assessments of respiratory function. This kind of thing is pretty widespread - one survey found that about a third of asthmatic kids had their inhalers taken away from them by school officials.

What happens when such practices are put into place? Students die. It has happened a number of times, but I’ll only link to the story of Catrina Lewis Michele Gaudin. Catrina died while school officials prevented her accessing her inhaler and spent a half hour trying to telephone her mother, before finally calling 911 to pick up the body. The life-saving murderous advice they gave to Catrina before she died was to go outside and get some fresh air. Her inhaler was locked in the school nurse’s office the whole time - they just wouldn’t let her use it.

Leaving the schools behind, there are still numerous examples of the asthmatic prejudice in the wider society that I’m sure any asthmatic could invoke. One of my favorites involves any time I was having an attack as a kid, and was told - and this happened often - to “just breathe” by some knowedgeable dumb-ass adult. I think I heard this from my gym teachers, parents of my childhood friends, extended relatives, and other well meaning, but very ignorant, people in my community.

Today, I’m active in athletics, despite having a significantly reduced lung capacity. Specifically, I like to ride bikes, and I have a high performance, tricked-out, all-carbon road bike with some nice components that weighs approximate 6/10^ths of an ounce that I like to ride as fast as I can. I ride in groups with some pretty fit riders, most of them about half my age. I can keep up, except when we hit the longer hills. Then my lungs just don’t allow it. I arrange ahead of time with my riding companions, telling them they can wait for me at the top, or they can just keep going and we need not finish together - it doesn’t matter to me. The few that wait? Well, when I get there, I’ve heard “just breath” a few too many times.

If we could breath, folks, we would.

Another is the admonishment that I’ve heard numerous times to just relax, and not sit up so straight during an attack. Got news for you - if I lay down during an attack, it gets way worse. If I recline on my couch, perhaps with some grapes and a couple of Roman slaves waving some white feather fans over me, the best that can be said is that I will have died in style. A kind of anachronistic, perverse style, but you see the point. Ignorant advice that I should just relax isn’t really needed here: Asthma isn’t a result of being high-strung. Being high-strung is a result of having to deal with idiots while I’m having an asthma attack.

The bottom line is that our culture views asthma in different ways; some see it as a medical condition and nothing more, and that’s fine. Others see it as a sign of personal weakness and a character flaw, and that’s not fine. That’s the heritage of the old establishment view of asthma as psychosomatic, requiring treatment with Freudian psychotherapy in order to make a better-adjusted person with fewer mental hang-ups.

Now, if you spent your life explaining to close friends and activity companions about certain of your limitations, in a responsible way so that they could make informed choices and not panic when confronted by these limitations - OR if you spent your life not disclosing these things and forcing others to deal in ignorance with what they considered to be unexpected and unexplained behavior on your part - and you had about half the people respond from the perspective of the “personal weakness” meme, would you consider suicide? How about some of your friends? I have no problem believing that this kind of social challenge would lead at least some people to suicidal thoughts and attempts.

Don’t get me wrong - I’m not piling on the researchers here. It is about time that someone took a look at the mental health attributes of asthma, now that 1 in 4 kids are getting it, and these researchers are doing a good thing. I reserve my ire solely for the irresponsible behavior and prejudices of people confronted by asthma. Fortunately, it is getting rarer as I age. Unfortunately, not as fast as I’d like, and until things get straightened out in the culture, an asthma-suicide link is going to have the ring of the obvious to me.

1. Clarke DE, Goodwin RD, Messias E, Eaton WW. Asthma and suicidal ideation with and without suicide attempts among adults in the United States: What is the role of cigarette smoking and mental disorders? Ann Allergy Asthma Immunol 2008;100:439-446. [↩]
2. Asthma and depression: a pragmatic review of the literature and recommendations for future research Clin Pract Epidemol Ment Health. 2005; 1: 18. Published online 2005 September 27. doi: 10.1186/1745-0179-1-18. PMCID: PMC1253523 Copyright © 2005 Opolski and Wilson; licensee BioMed Central Ltd. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1253523 [↩]
3. Within my lifetime. [↩]

Writerdd over on Skepchick, who is quickly becoming one of my favorite bloggers, has some remarks about non-fundamentalist religion:

In comments on another post a few weeks ago, I questioned the idea of criticizing Christians for “cherry picking the Bible” — that is, ignoring the parts they find abhorrent and clinging to the parts they find inspirational…. Ignoring parts of the Bible or Koran should not be ridiculed. It is a good thing that leads away from fanatical violence. We should be encouraging this type of behavior.

I agree, utterly and completely.

The fact is, sensible people will read parts of the Bible and correctly discern that it isn’t a science textbook. In a recent TV interview on the evolution wars, I said that a person reading the first four chapters of Genesis as a story that tells us about human nature - our curiosity, our response to authority, etc - has done a sensible thing. Not as sensible, perhaps, as studying psychology, but they’ve at least read the text and learned from it the things that I think the author was trying to teach. Somewhat more discerning people might read the same text and recognize that it is also a slap in the face to prevailing political and religious institutions in contemporary Babylon - and if so, they’ve done an excellent job of interpreting the text.

Readers who decide those chapters are an anatomy lesson and come to the conclusion that men have fewer ribs than women¹ have made a fundamental error about the scope of the text. As have those who believe that it is a textbook for science and/or history. If someone reads the first four chapters of Genesis and still thinks that men and women have the same number of ribs, does it make them an infidel,² or somehow not-really-Christian³?

Ummm, no, it makes them more sensible than their peers.

In doing the science/skepticism educational activities I’m neck-deep in, I have to communicate with forthrightly religious people all the time. The sensible ones, who lack fundamentalist impulses, have no difficulty grappling with the reality that is demonstrated by experiment. And lest we body-check them for nevertheless believing in god, let’s keep in mind that all but the superheroes among us believe something that isn’t true⁴.

Dialogues often develop between fundamentalists and less strident religionists in the class discussions that I lead, and my conclusion from these experiences is that I want more of the latter in my world. They are simply much less prone - no, let’s say, not prone at all - to condemning me to a violent end for “believing in” the Big Bang Theory, and shutting out everything I have to say simply because my beliefs aren’t the same as theirs. What’s disturbing about that is my “beliefs” are never aired - they just assume the person they are dealing with is a minion of Satan. As writerdd notes, there is a big gulf in social adjustment between these two populations.

And that is why I distinguish between religious extremists, and everyone else. (Well, that, and because the term marginalizes extremists.)

1. This is a belief I have actually encountered in the wild. [↩]
2. From the perspective of fundamentalist Christians. [↩]
3. From the perspective of an atheist or adherent to another religion. [↩]
4. That’s actually the most humbling thing about doing science - finding out that your view of reality is seriously messed up, over and over again. [↩]