Addiction in health care professionals

March 4, 2014

Addiction in health care professionals-The untold story

One group of professionals (healthcare providers) have greater access to addictive drugs in their workplace, which can accelerate addiction

The abuse of prescription drugs-especially controlled substances-is a serious social and health problem in most states today. People addicted to prescription medication come from all walks of life. The last people we would suspect of drug addiction are health care professionals-those people trusted with our well-being in issuance of medically correct drugs. Unfortunately, health care workers are as likely and are vulnerable as anyone else to abuse drugs.

The vast majority of Drug Enforcement Agency (DEA) registered practitioners comply with the controlled substances law and regulations as stipulated in various laws in different states. However, drug impaired health professionals are one source of controlled substances diversion. Many have easy access to controlled substance medications. Some will divert and abuse these drugs for reasons such as relief from stress, self-medication, or to improve work performance and alertness.

Addiction in healthcare professionals-Responsibilities of DEA

DEA-registered health practitioners have a legal and ethical responsibility to help protect society from drug abuse. They have a professional responsibility to prescribe and dispense controlled substances appropriately and decisively to the consumers. They guard against abuse while ensuring that patients have medication available when they need it. They have a personal responsibility to protect their practice from becoming an easy target for drug diversion, in other words they ore all the patient the duty of care in all respect and discipline. They must become aware of the potential situations where drug diversion can occur and what to do to prevent it well before it happen. The safety of the patients must be their ultimate objective and at no given time must this change or be seen to be changing.

Addiction in healthcare professionals-Recognizing a drug impaired coworker

Drug abusers often exhibit similar unusual behavior. The following signs and symptoms may indicate a drug addiction problem in a health care professional:

Absences from work without notification and an excessive number of sick days used
Frequent disappearances from the work site-frequent or long trips to the bathroom or to the stockroom where drugs are kept
Excessive amounts of time spent near a drug supply
Volunteering for overtime and working when not scheduled to be there
Unreliability in keeping appointments and meeting deadlines
Work performance which alternates between periods of high and low productivity; mistakes made due to inattention, poor judgment and bad decisions
Confusion, memory loss, and difficulty concentrating or recalling details and instructions
Ordinary tasks require greater effort and consume more time
Strained or neglected interpersonal relations with colleagues, staff and patients
Rarely admits errors or accepts blame for errors or oversights
Heavy “wastage” of drugs
Sloppy record keeping, suspect ledger entries and drug shortages
Inappropriate prescriptions for large narcotic doses
Insistence on personal administration of injected narcotics to patients
Progressive deterioration in personal appearance and hygiene
Uncharacteristic deterioration of handwriting and charting
Wearing long sleeves when inappropriate
Personality changes-mood swings, anxiety, depression, lack of impulse control, suicidal thoughts or gestures
Patient and staff complaints about health care provider’s changing attitude/behavior
Increasing personal and professional isolation

Addiction in healthcare professionals-The decision to get involved

Health care professionals often avoid dealing with drug impairment in their colleagues. There is the fear that speaking out could anger the coworker, resulting in retribution, or could result in a colleague’s loss of professional practice. Many employers or coworkers end up being “enablers” of health care practitioners whose professional competence has been impaired by drug abuse.

Drug impaired coworkers are often protected from the consequences of their behavior. However if you ever identify any signs or symptoms in a coworker, it will be wise and important that you show great concern towards the fellow staff. Someone’s future could be jeopardized if you cover up and choose not to report your concerns. By becoming involved by way of reporting and showing concern you may be doing several positive things like:

Helping someone who may be doing something illegal
Protecting the safety and welfare of an addicted employee or coworker
Protecting patients or other people who could suffer at the hands of a drug addicted individual

Addiction in healthcare professionals-If drugs are being sold or stolen

If you suspect that a drug deal or syndicate is in progress, do not intervene on your own, this may be dangerous because you may not know how well organized the syndicate is. Contact the organization security or better still notify the police. If you are a DEA registrant and become aware of a theft or significant loss involving controlled substances, you must immediately report the theft or loss. You should go to the nearest DEA office as well as your local police department by doing this you will be helping a great deal on dealing with drug addiction within the healthcare professional sector.

What you can do to help

For some employees, a supervisor talking to them about their poor work performance is enough to help them change. Many drug abusers will seek help for their problem if they believe their job is at stake. This may be true even if they have ignored such pleas from other people important in their life. A referral to the Employee Assistance Program is often the supervisor’s course of action.

Drug addicts can recover, and effective help is available. Encourage your coworker or employee to seek drug treatment assistance. Treatment programs range from self-help to formal recovery programs. You may suggest they contact the Employee Assistance Program for help in determining the appropriate level of care. The EAP and the treatment programs will maintain the confidentiality of those seeking assistance to the greatest extent possible.

Addiction in health care professionals-The untold story

Lyme disease and Relapse

March 4, 2014

Lyme disease and Relapse-Reinfection versus Relapse

Erythema migrans.

Lyme disease is the most common tick-borne infection in the United States and Europe. Clues to differentiating reinfection from relapse of Lyme disease

During both the initial infection and subsequent episodes, the majority of patients with Lyme disease manifest the distinctive skin lesion erythema migrans. In untreated patients, erythema migrans resolves spontaneously within a median of about twenty eight days, but relapse may occur within a longer period, usually within a year or so of the appearance of the initial lesion. After treatment with presently recommended antibiotic regimens, however, persistence, progression, or recurrence of the skin lesion or the development of objective extra cutaneous manifestations of Lyme disease is exceedingly rare.

Relapse has been well-documented (on the basis of recovery of B. burgdorferi by culture) only in patients treated with antibiotics like cephalexin also known to have poor activity in vitro against this microorganism, although some patients treated with certain macrolides also appear to experience relapse clinically. Thus, the development of a new erythema migrans lesion in a person with a prior history of Lyme disease who was treated with recommended regimens is prima facie evidence for reinfection.

Clinical features that suggest reinfection rather than relapse include the development of an erythema migrans lesion at a site different from that of the original lesion and the presence of a punctum in the lesion. A punctum is a small raised or depressed point near the center of a primary erythema migrans lesion, representing the site from which the tick detached. In the United States, repeat episodes of erythema migrans due to reinfection almost always develop in a subsequent transmission season during the late spring or summer (R.B.N., unpublished data) at the time when nymphal stage (i.e., the stage that is the principal vector for Lyme disease) scapular’s or Ixodes pacificus ticks are most abundant. In Eurasia, reinfection, usually transmitted by nymphal Ixodes ricinus or adult Ixodes persulcatus, is also expected to occur mostly during the late spring or summer. In contrast, cases of relapse of preexisting infection would not necessarily be expected to occur in a seasonal pattern and would be likely to arise within a few weeks to several months after the initial episode.

Lyme disease and Relapse-Differentiating reinfection from relapse

Limited data are available regarding the clinical manifestations of second episodes of erythema migrans in patients with Lyme disease who have reinfection. A recent report described twenty eight patients from Block Island, Rhode Island, who had repeated episodes of erythema migrans and were believed to have been re-infected with B. burgdorferi (five additional persons had only “flu-like illnesses” as either their first or second episode of infection but were considered to have Lyme disease on the basis of seroconversion). None of the patients had clinical evidence of immunodeficiency. Persons with reinfection were equally distributed by sex; however, 6 (86%) of 7 persons who experienced a third episode of Lyme disease were female. This finding is difficult to explain but is consistent with the observations in a recent Swedish study, in which the investigators found that twenty seven of thirty one re-infected persons were women aged 44 years old.

Lyme disease and Relapse-Analysis

As one would predict, nearly all cases of recurrent infection in the Block Island study occurred during the late spring or summer. The number and severity of symptoms were similar in the first and second episodes and appeared to be less severe during the third episode, although these findings were not statistically significant. Surprisingly, all patients with recurrent Lyme disease did not seek medical attention sooner than did those who had only a single episode. That was very interesting.

A preliminary report summarized findings for eleven men and another eleven women with who each experienced two episodes of erythema migrans and were seen at our institution; the episodes occurred a mean (±SD) of 3.25 ± 2.65 years apart. A prior tick bite at the site of erythema migrans was recalled with similar frequency in patients who experienced first and second episodes. Patient symptoms (including fever), diameter of erythema migrans, abnormal findings on physical examination, and laboratory results (complete blood count, transaminase levels, and erythrocyte sedimentation rate) during second episodes were similar to those during first episodes. These findings were also similar to those for contemporaneous control subjects who experienced single episodes of erythema migrans. This study obviously had insufficient power to detect relatively small differences.

In this study, patients were >2 times as likely to have multiple erythema migrans skin lesions (a marker of hematogenous dissemination of B. burgdorferi infection) during their first episode of Lyme disease than during their second episode (7 [32%] patients during the first episode vs. 3 [14%] patients during the second episode; P = .15). Although this finding could be a chance event, alternatively, it could be related to the development of partial host immunity, leading to protection from hematogenous dissemination after reinfection

Lyme disease and Relapse-Reinfection versus Relapse

Sleep Disorders and Lyme disease

March 3, 2014

Sleep Disorders and Lyme disease-Discussed

Lyme disease can be avoided if sleep disorder is avoided. Get good sleep

You would normally think that by feeling sick it would be so easy to fall asleep! This theory disturbed my mind and I decided to do a bit of research to find some of the common types of sleep disorders, possible causes, the effects of sleep deprivation, how it ties into Lyme disease, and what we can do to try to get a full night of rest. Having a sleep disorder is a broad term for many types of disturbances in one’s sleep.

Sleep deprivation is considered a condition and is a general term of not having enough sleep. This can be chronic, or it can only least for a short period of time. It is a common occurrence, as with healthy people 1 out of 5 people suffer from sleep deprivation. According to sleepfoundation.org, they recommend an adult to have 7 to 9 hours of sleep. Having a chronic illness however, you might need a few more hours to feel more refreshed. Careful though! According to researchers, there IS such a thing as too much sleep, that can leave you feeling even less restored.

There are two types of sleep. Rapid eye movement (REM) and non-rapid eye movement (NREM). REM sleep is the level of sleep where dreaming occurs, and accounts for about 20% your night of sleep. NREM accounts for the 80% of your sleep, and is divided into 4 stages. One and two are light sleep; three and four are deep sleep. Deep sleep is also known as slow wave sleep (SWS) actually begin a few minutes after you fall asleep and is the most refreshing and restorative type of sleep you have. This right here is why you feel more restored if you take a short nap versus a long one!

These SWS is only about 10-20% of your sleep, but it is needed for cell and musculoskeletal tissue regeneration, your cardiovascular system, normalizes blood pressure, hormones, and your metabolic system.

Hypersomnia

Hypersomnia is a term for a large group of disorders characterized by daytime sleepiness.

Insomnia

Insomnia means sleeplessness, the inability to fall asleep or stay asleep.

There are 3 subcategories of these two different categories: intrinsic, meaning from within the body, extrinsic, meaning pathological conditions and disturbances of circadian rhythm, which means the physical mental and behavioral changes that follow a 24 hour cycle.

Sleep Disorders and Lyme disease-Types of sleep disorders

Sleep Apnea is more common disorder among Lyme patients. Sleep apnea means you have one more pauses or shallow breaths in your sleep. Some explanations for Lyme patients having this condition are that most chronic Lyme’s have neurological dysfunction. With the Neuro dysfunction of the palara and uvula are a possible cause. Brain abnormalities are reasoning for this to occur is the floppiness tissues in the back of the throat. Lyme patients with this condition seem to:

Involuntarily grinding or clenching your teeth while sleeping. It can interfere with sleep, and could be a high contributor to jaw pain and headaches as well. Cranial sacral therapy is a good choice to help ease the symptoms if you are suffering from this.

Delayed sleep phase disorder, (or DSPD) is the inability to awaken and fall asleep at socially acceptable times but will stay asleep. This is a disorder of circadian rhythms.

Sleep Disorders and Lyme disease-Symptoms of sleep disorder

Poor immune system function, higher blood pressure (higher risk of heart attack or stroke), being overweight (can cause diabetes among other health issues), clenching teeth at night, decreased body temperature, tremors, fibromyalgia symptoms, extreme fatigue and a variety of psychological effects.

Effects of psychology: Of course your psyche is going to be a little off teeter without enough sleep. Some of these issues include symptoms similar to ADHD, hallucinations, slower reaction time, depression, anxiety, irritability, memory lapses, among other issues. That’s a lot. Shows how important it is to get a good night’s rest.

Sleep Disorders and Lyme disease-There are many causes of sleep disorders

Nutritional deficiencies: the main one being magnesium. It is very common among Lyme’s. A magnesium deficiency can cause an array of problems along with sleep disruptions. Others to consider are calcium, folic acid, iron, and your B vitamins (especially B6 and 12) to name a few. I should note though, don’t take your B’s too close to bed! Yes, you need them, but they can cause you to have a harder time falling asleep as well as cause vivid dreams.

Hormone imbalances: Check your Cortisol levels! Cortisol = stress hormone. When it is high (another common abnormality of Lyme’s), it can cause you to not be able to fall asleep. Reduced levels in testosterone in men can cause sleep apnea. Women’s number one hormone issue associated with sleeping problems is lower progesterone levels.

Low blood sugar: Try sticking with a healthy diet for tips to eat a proper diet for those with Lyme disease. Stress can hinder sleep because it produces two things called epinephrine and non-epinephrine, which stimulate the nervous system, which triggers a fight or flight” response in your body, keeping you up. HPA and ACTH, two chemicals responsible in stress response mostly related to an external stressor, AKA Lyme, can also keep you awake at night.

Lack of darkness: I know this isn’t a physiological problem, like I have listed above, but I felt like it deserved to be up here. Before you go to sleep, your body starts producing melatonin, a chemical in your body that makes you sleep and is essential for a restful sleep. This chemical continues to be produced when you are sleeping, with its highest production between 2 a.m. and 4 a.m. Experts say that without total darkness, the effects of this are much less, causing a lessened effect.

There are other causes are ones that we ourselves can do our best to stop doing, as we might not even be aware that our habits are keeping us awake at night. Poor sleep planning is the main one. Trying to go to bed and wake up at the same time and having a schedule is very important. Working night shifts can cause sleep problems since it causes your body to get out of a normal sleeping pattern, caffeine and other stimulants (check your meds, some have stimulants you might not be aware of!), sleeping with your pets (they can get up and down, or move too much), eating too close to bedtime (digestion disrupting sleep), alcohol and nicotine, exercising too close to bedtime (yeah us Lyme’s are super active!.. but you know what I mean), ELECTRONIC DEVICES IN THE BEDROOM, among other things that we can change ourselves and try to help aide us get a good night’s rest.

The main issue with sleep deprivation and Lyme is that without a good night’s rest, you are hindering the healing process. Sleep fixes and restores what you did during the day, and believe it or not, when treating Lyme, our bodies’ peak at fighting the little bastards when we are asleep.

So what does one do when they just can’t get to sleep or stay asleep?

Well, there are many things you can do, whether it is by your own actions or things you can personally do, or take natural supplements or pharmaceuticals to be able to aid in this process such as a sleep schedule, substances, electronics, and need for darkness, but others include avoiding stimulating activity right before bed, meditation, or taking a warm bath before bedtime.

Sleep Disorders and Lyme disease-Discussed

Living with Lyme disease

March 3, 2014

Living with Lyme disease-Tips

keep away from tick infested locations and be safe from Lyme disease

Lyme disease being what it is and all the confusions around it, it is important that we get to know how to live with this scourge, and for this reason let us look at a few things that we can do to be comfortable while living in this condition.

Living with Lyme disease-Sun sensitivity

For those people who are taking doxycycline and are strongly affected by the sun using sunscreen would be fine because it is ineffective against the sun sensitivity side effect that you get with doxyclicine, which can quickly lead to painful burns on your skin.

But better still stay indoors during the middle of the day (when there is a high UV index), or wear long sleeve shirts and long pants (with a UV protection in them if you can), as well as a wide brimmed hat and sunglasses. For those who are very sun sensitive you can also wear light gloves as well.

Probiotics – if you are taking antibiotics for your Lyme disease it is essential that you take a good probiotic at least 2 hours after your antibiotics. This is because antibiotics kill off the good and bad bacteria in your gut, which means that you are susceptible to a clostrium difficile infection, which can be fatal. For this reason, taking probiotics is essential for when you are taking antibiotics, and for about 2-4 weeks after you finish your antibiotic treatment.

Blood tests – because some of the medications used to treat Lyme Disease can be very strong, and because when the Lyme Disease bugs die off they produce neurotoxins that can damage your brain and other organs, it is important that you have regular blood tests to check your liver and kidney function. It is also vital that you regularly check your white cell and neutrophil counts as well, so you can know how your immune system is coping with the side effects of the treatment as well as the disease itself.

Co-infections – studies have shown that almost all people who have Lyme disease have some sort of co-infections that they got at the same time as their Lyme disease. Co-infections can include Babesia, Bartonella, Clamydia Mycofermentans, Ricksettia etc. It is vital that you treat the co-infections as well as the Lyme disease infection – this because many of these co-infections depress the immune system making it difficult to fight off other infections.

Living with Lyme disease-Immune System

When your immune system is low, it is vital that you stay away from people who may be sick. Many people who die from Lyme disease die from infections they have picked up from other people (such as chest infections. If your immune system is very low, consider making people wear masks and use an antiseptic hand-wash each time they enter your house. If you are in hospital, have a friend with you & get them to insist on medical and general staff washing their hands each time before they touch you (you’d be surprised how many hospitals are full of really dangerous bugs, and even more surprised at how many medical and general staff don’t wash their hands when they should). You & your friend will be annoying, but this simple precaution may save your life.

Hot weather – many people with Lyme disease find that they get sicker in hot weather. For this reason if you live in a hot climate you will need to stay indoors (in air-conditioning if you can) during the day and go outside after the sun has gone down and the temperature have dropped. Hot humid weather is often more difficult to cope with than hot dry weather.
Hot flushes / Night Sweats – if you are struggling with a Babesia co-infection and are having difficulty getting through the night due to hot flushes and night sweats, I would recommend a small portable fan beside your bed. When you are hot sleep facing the fan, and when you cool down roll over and sleep facing the opposite direction. This will help you control your body temperature more easily during the night.

Living with Lyme disease-Diet

Many people with Lyme disease have to be very careful with their diet. This is because Lyme disease affects the immune system, and because of the side effects of the medications used to treat Lyme disease. If you are taking oral antibiotics it is vital that you do not eat sugar – this is because oral antibiotics kill all the bacteria in the gut – good and bad bacteria. If you eat sugar you feed mainly the bad bacteria (they love sugar) and run the risk of getting a clostridium difficile infection, which is potentially fatal.

In order to heal from Lyme disease it is important that your immune system is functioning at its best. When you eat or drink sugar based food and drink your immune system is temporarily depressed for up to 12 hours. Many people with Lyme disease have damaged gastrointestinal systems, and so need to avoid foods that place extra stress on the gut such as gluten (wheat) and dairy

Long Haul – get ready for your Lyme disease treatment to be quite lengthy. The average time spent being treated for Lyme disease is two years. Some people need less time than this, and some people require much longer treatment. Treated correctly many people are able to go into remission, but find that when their immune system is under stress (such as during another severe illness or pregnancy), or when they are in stressful situations (such as high pressure jobs or during high stress family events such as births, deaths and marriages) that their Lyme disease can come back – it is important to keep a close eye on your health, even when you are able to get into remission with Lyme Disease so that you can get on top of any relapse quickly.
Living with Lyme disease-Tips

Lyme disease

March 3, 2014

Lyme disease-What is it?

Some of the diseases you can get from a tick bite are Lyme disease, ehrlichiosis, Rocky Mountain spotted

To understand this disease better, it will be important that we trace its causes, treatment and prevention. By the way what is this disease? Lyme disease is caused by the bacterium Borrelia burgdorferi and is transmitted to humans through the bite of infected blacklegged ticks.

Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. If left untreated, infection can spread to joints, the heart, and the nervous system. Lyme disease is diagnosed based on symptoms, physical findings (e.g., rash), and the possibility of exposure to infected ticks.

Scientific laboratory testing is helpful if used correctly and performed with validated methods. Most cases of Lyme disease can be treated successfully with a few weeks of antibiotics. Steps to prevent Lyme disease include using insect repellent, removing ticks promptly, applying pesticides, and reducing tick habitat. The ticks that transmit Lyme disease can occasionally transmit other tick-borne diseases as well.

Lyme disease-Natural treatment of Lyme disease

It is a common misconception that Lyme disease is primarily an “East Coast” problem. Within the last 10 years, however, the ticks that are known to carry Lyme disease have been found in all 50 states in the US and in other countries around the globe. We are now facing a nationwide epidemic of Lyme disease.

Uncovering some of the myths about Lyme disease is an important step in both prevention and treatment. Efforts are being made to spreading awareness and education about this illness. One of the biggest challenges with Lyme disease is that it can be difficult to get a confirmed diagnosis without a known tick bite or the appearance of the classic “bull’s eye” rash. There are many different skin rashes that are associated with Lyme disease, however, and some are easily mistaken for skin infections or other insect bites.

It is important not to make assumptions that you don’t have Lyme disease if you don’t have a rash. Some of the symptoms associated with this infection include fatigue, poor memory and concentration, irritability, anxiety or depression, muscle and joint aches and pains, palpitations, headaches, insomnia, and numbness and tingling.

Lyme disease is now commonly referred to as “the great imitator” because the similarities of symptoms with other illnesses. This can be frustrating for patients in search of answers to explain how they are feeling. Getting a good clinical evaluation of symptoms by a physician is crucial in diagnosing Lyme disease.

The conventional treatment of Lyme disease includes antibiotics in the early stages of infection. At the later stages, it may become more complicated and difficult to treat as multiple systems are often involved and immunity is suppressed. A holistic approach to treatment is very effective in restoring the body back to health by targeting the multiple infections associated with Lyme and simultaneously strengthening the immune system.

The natural approach incorporates a unique variety of different modalities to treat infection while supporting the immune system and decreasing symptoms. Many herbal protocols including Chinese herbs have proven effective clinically in the treatment of Lyme disease. Acupuncture can be used to stimulate circulation and decrease pain. Adequate nutrition and a good detox protocol can minimize the symptoms that occur as a result of “die-off” of the infection.

Lyme disease-Pain, Stress and Addiction

People who struggle with stressful medical conditions such as Lyme disease are more vulnerable to addiction say scientists at the National Institute of Health (NIH). In fact statistics supplied by the United States Department of Health and Human Services (HHS) show that individuals with chronic pain experience substance abuse rates at two-to-four times that of the general population. Several factors that explain their susceptibility include the following:

Ongoing need for medication
Ongoing health problems
Societal enabling
Lack of identification of potential problems

Stress is another factor that can predispose individuals who live with chronic pain to addiction. Researchers have long identified a correlation between stress and substance abuse. Important facts about this link include the following:

Stress is a major contributor to the initiation and continuation of substance abuse.
Children who are exposed to severe stress are more vulnerable to substance abuse in adulthood.
30-60% of individuals with substance use disorders meet the criteria for comorbid PTSD.
Patients with substance use disorders tend to suffer from more severe PTSD symptoms than PTSD patients without substance use disorders.
Animals that are not previously exposed to illicit substances become more vulnerable to drug self-administration when stressed.
Many of the same neurocircuits that respond to drugs also respond to stress.

Stress increases the release of corticotrophin-releasing factor (CRF), a hormone that catalyzes biological responses to stressors such as increased heart rate and metabolism. Abusing drugs also increases CRF levels and thereby heightens danger of relapse.

Stress also triggers the fight-or-flight moderating amygdala. When the amygdala perceives threats, it responds irrationally and hijacks the individual’s ability to think clearly. For people in recovery who stay sober by making wise choices, this emotional takeover can impair judgment and make resisting drugs harder.

There is yet another way that stress packs a double punch for people who suffer from Lyme disease. It exacerbates pain. A research team from Carnegie Mellon University found that chronic psychological stress is associated with the ability to regulate the body’s inflammatory response. This can lead to the development or progression of disease.

Lyme disease-New Ways to Cope

Mastering stress reduction skills is an important part of overall health and sobriety. In treatment many people find ways to incorporate relaxation strategies into daily life. Several include the following:

Singing
Massage
Spending time outdoors
Journaling
Yoga
Adopting a dog
Listening to music
Taking a walk
Drawing
Soaking in a hot bath

Other stress-management skills and techniques frequently taught in recovery programs include the following:

Avoiding hunger, anger, loneliness and fatigue
Engaging in community service
Journaling thoughts and feelings
Practicing positive thinking

Experts at the Centre for Addiction and Mental Health [OB1] also advise active self-monitoring of mood changes by keeping a list of personal warning signs. Additionally they suggest identifying enjoyable activities that generate positive feelings and could serve as a way to neutralize a craving or negative mood. The key is to pay attention to changes. Sleep disturbances, hopeless thoughts and appetite fluctuations are sometimes early relapse warning signs.

Category Archives: Dr. Dalal Akoury