The study examined 2 groups of mice who were fed either a diet containing Lactobacillus rhamnosus (a beneficial bacteria found in dairy products and many probiotic supplements) or a diet without this bacteria. Emotional and mood states of each group of mice were evaluated and it was found that the mice fed the diet with L. rhamnosus generally responded to tests in such a way that suggested improved mood and decreased anxiety than the group of mice fed a diet without probiotics. In addition, the L. rhamnosus-fed mice exhibited lower levels of corticosterone than the mice fed a diet without probiotic organisms. (Corticosterone is a hormone secreted in response to stress.) Furthermore, all of these differences disappeared when the vagus nerves of the mice in both groups were cut, suggesting that the effects were mediated by gut-brain communication.

While the above study was conducted on animals and the results are not directly translatable to humans, evidence from other studies suggest reason to pursue this research further:

- There is evidence that probiotics (and prebiotics) can improve mood and decrease anxiety in patients with irritable bowel syndrome and chronic fatigue syndrome.^2,3

- Epidemiological evidence has identified an association between neurodevelopmental disorders (such as schizophrenia) and microbial pathogen infections during the perinatal period.⁴

- Colonization of the gut with beneficial microbes can impact brain development and subsequent adult behavior (according to another recently published study in the Proceedings of the National Academy of Sciences⁵).

Thus it seems all the more important to consider not only treating the brain and nervous system in those suffering from mental-emotional distress, but also to focus on gastrointestinal health. No wonder so many herbs and natural remedies that are of benefit to the nervous system are also of benefit to the gastrointestinal system—the health of each system may be more interdependent than modern medicine has heretofore appreciated.

References:

¹Bravo JA,  Forsythe P, Chew MV,  et al. (2011) Ingestion of Lactobacillus strain regulates emotional behavior and central GABA receptor expression in a mouse via the vagus nerve. Proc Natl Acad Sci USA 108:16050-55.

²Rao AV, Bested AC, Beaulne TM, et al. (2009) A randomized, double-blind, placebo-controlled pilot study of a probiotic in emotional symptoms of chronic fatigue syndrome. Gut Pathog 1:6.

³Silk DB, Davis A, Vulevic J, et al. (2009) Clinical trial: The effects of a trans-galactooligosaccharide prebiotic on faecal microbiota and symptoms in irritable bowel syndrome. Aliment Pharmacol Ther 29:508-18.

⁴Mittal VA, Ellman LM, Cannon TD (2008) Gene-environment interaction and covariation in schizophrenia: The role of obstetric complications. Schizophr Bull 34:1083-1094.

⁵Heijitz RD, Wang S, Anuar F, et al. (2011) Normal gut microbiota modulates brain development and behavior. Proc Natl Acad Sci USA 108:3047-3052.

The Economist, 400(8749), 80-81.

April 17, 2012  Robert Whitaker, Author of Anatomy of an Epidemic, returns to Portland to speak on

“Where We’ve Been & Where We’ re Going“ in mental health.

April 28, 2012  Fundraising Music Concert for Mental Health: Step Into Wellness with TARANA  

The fundraiser supports ASHA International’s Programs in:

• Mental Health Education
• Wellness Workshops
• Cultural Competency Training
• Peer Mentoring & Support Groups
• Referrals & Resources

I hope that these events &/resources are of help to you – it could be a busy month…!

So here are some highlights of Mental Health in the Media this month:

• Massachusetts General Hospital (MGH) Center for Women’s Mental Health is a Center for Perinatal and Reproductive Psychiatry and has an excellent blog on this topic. This month’s posting “Children of Depressed Mothers Exposed to Multiple Risk Factors for Psychopathology” captures not only some important findings regarding Children of Depressed Mothers and their risk factors for later-life psychopathology, but also speaks to the dramatic increase in research in (Reproductive) Psychiatry. http://www.womensmentalhealth.org/posts/cwmh-briefs-a-sampling-of-what%E2%80%99s-new/ ²
• 
  

• Charlie Rose, of the Charlie Rose Show, continues the ‘Brain Watch Series’ interview s the authors of The Emotional Life of the Brain by Richard J. Davidson and Sharon Begley who examine 6 proposed emotional styles and traits and what these may explain about one’s susceptibility to mental illness. They also discuss how knowledge of these styles can improve one’s outlook and life. You can watch the interview in its entirety at: http://www.charlierose.com/view/interview/12227 ³

• Christopher Lane, the author of several books including Shyness: How Normal Behavior Became a Sickness and author of Psychology Today’s “Side Effects” Blog, is interviewed in the March issue of Sun Magazine. The interview is entitled Side Effects May Include. Christopher Lane On What’s Wrong with Modern Psychiatry. This interview is an in-depth conversation on the origins and evolution of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) and the state of affairs of psychiatry today. You can read an excerpt of this article at: http://www.thesunmagazine.org/issues/435/side_effects_may_include ⁴   

• eyes & ears is a Mental Health Survivor/Consumer Newsletter supported by Cascadia Behavioral Healthcare and the Mental Health Association of Portland. Each month there are news and highlights about mental health resources and events locally and beyond. The March issue can be found at: http://www.mentalhealthportland.org/wp-content/uploads/2012/03/ee1203March2012online.pdf ⁵

 There are so many more resources out there… more to come in time…

If there are resources that you have found particularly interesting or helpful that you would like me to share with others, please email me and I will review them for my Resources page and future educational materials. Thanks for reading!

References:

¹Whitaker, R. (2010). The Anatomy of an Epidemic. Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York, NY: Crown Publishers.

² Massachusetts General Hospital (MGH) Center for Women’s Mental Health. (2012, Mar.).  CWMH Briefs: A Sampling of What’s New. Retrieved from http://www.womensmentalhealth.org/posts/cwmh-briefs-a-sampling-of-what%E2%80%99s-new/

³ Rose, Charlie. (2012, Mar. 12).The Emotional Life of Your Brain. [Interview of  Richard J. Davidson, Ph.D. and Sharon Begley on the Charlie Rose Show]. Retrieved from http://www.charlierose.com/view/interview/12227

⁴ Cooper, A. (2012, Mar.). Side Effects May Include. Christopher Lane On What’s Wrong with Modern Psychiatry. The Sun. Retrieved from http://www.thesunmagazine.org/issues/435/side_effects_may_include

⁵ Green, D. & Haataja, D. (2012, Mar.).  eyes & ears. A Mental Health Survivor/Consumer Newsletter Retrieved from http://www.mentalhealthportland.org/wp-content/uploads/2012/03/ee1203March2012online.pdf ⁵

“I can easily imagine giving a patient a good (homeopathic) remedy for eczema and placing them on a deserted island fully expecting them to get better. But I do not imagine this to be true of the patient who is suffering from depression or from a compulsive disorder. These patients need to be in relationship, they need the relational field to heal.” ¹

In my practice, I place great value on the relationship that I have and foster with my patients, for without a connected, trusting and caring relationship, healing does not occur, no matter how powerful the medicine. I have observed homeopathy to heal through relationship. I see remedies as restoring one’s relationship to oneself and to the external world on multiple levels.  In so doing, it changes one’s relationship to one’s ailment. Time and again I have seen someone debilitated by a condition, let’s use a case of eczema as an example. The individual is prescribed a single homeopathic remedy and  when they return for a follow-up soon after taking the remedy and are asked how their skin is, though it does not yet look any different, they report that it no longer bothers them?! And then I know that a more complete shift and resolution of their symptoms will soon follow as their relationship to their symptoms has changed and the healing process has begun.

This brings us to a brief examination of illness. Arguably there are pathogenic organisms that afflict us, but many would contend that it is the terrain versus the germ that determines what and if we are affected by an organism or condition.

Florence Nightingale “There are no specific diseases; there are specific disease conditions.” 

William Osler “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”

I tend to agree with this viewpoint in most cases and link this back to relationship. It is the harmonious relationship between our bodily systems, our mind and our environment that determines health from a naturopathic perspective. When these systems are in right relationship, health is to be had. When these systems are imbalanced, symptoms appear, and ultimately more severe conditions manifest if the imbalances are not addressed.

So what does the modern medical literature have to contribute to this discussion? Evidence comes from studies on the efficacy of psychotherapy and from studies on the placebo effect. Compelling evidence on the efficacy of psychotherapy can be found in a 2010 article by Jonathan Schedler, entitled “The Efficacy of Psychodynamic Psychotherapy”, in which an in-depth review of the literature in the field is presented. Schedler speaks to the importance of the psychotherapeutic relationship:

“The relationship between therapist and patient is itself an important interpersonal relationship, one that can become deeply meaningful and emotionally charged….The recurrence of interpersonal themes in the therapy relationship (in theoretical terms, transference and countertransference) provides a unique opportunity to explore and rework them in vivo. The goal is greater flexibility in interpersonal relationships and an enhanced capacity to meet interpersonal needs.”²

The placebo effect has been widely studied and can be summarized very simply as the effects of treatment that cannot be attributed to the medicine itself. The placebo effect can thus be considered the effect that results from the doctor-patient relationship and the patient’s expectation/hope/belief that the treatment will be helpful.  A recent 60 minutes episode interviewing psychologist Irving Kirsch, the associate director of the Placebo Studies Program at Harvard Medical School, says that his research challenges the effectiveness of antidepressants (especially for mild-moderate depression). You can view his interview at: http://www.cbsnews.com/video/watch/?id=7399362n ³ .

Finally to extend this discussion a little farther, the relationship of medicine needs to heal. Our current state of affairs is a fragmented system which often leaves practitioners and patients unsatisfied and unwell. I feel that greater collaboration and integration could bring some healing into the medical sphere. This spring I hope to present a case which illustrates the healing potential of integrative care. This was a case in which I collaborated with a psychiatric colleague in treating a case of alcoholism, obsessive-compulsive disorder and depression using a combination of homeopathy, nutrition, herbal medicine, psychotherapy and antidepressants with good long-term results. More to follow…

References:

¹ Heron, K. (2012). Expectations. Simillimum. Journal of the homeopathic academy of naturopathic physicians, 2011/2012(XXIV), 43-45.

² Schedler, J. (2011). The Efficacy of Psychodynamic Psychotherapy. E-Journal of American Psychologist, 65(2), 98-109. Retrieved from http://www.apa.org/pubs/journals/releases/amp-65-2-98.pdf

³ Stahl, Leslie. (2012, Feb 19.) .Treating Depression: Is there a Placebo Effect. [Interview of Irving Kirsch, PhD. on 60 minutes]. Retrieved from http://www.cbsnews.com/video/watch/?id=7399362n

In thinking of what health information would help your New Year start off on the right foot, I thought of health habits that while simple, can make a big difference in overall health. One of the most important health habits to adopt in my view is to eat more vegetables, particularly dark green leafy vegetables. So you can imagine my good fortune when I learned of a more compelling way to present all of this to you -eating more greens on New Year’s day is considered lucky! Cooked greens are consumed in a number of different countries for the New Year holiday as they are considered a symbol of economic fortune (the folded green leaves are said to look like folded money). ¹  So now eating your greens are not only healthy (we will discuss more why in a moment), but also lucky!

Why are dark green leafy vegetables so healthy you might ask? Well not only are they rich in fiber, Omega-3 fatty acids, vitamins (particularly vitamins A & C) and minerals (calcium, iron and magnesium to name a few), but they also contain a host of beneficial phytochemicals (betalains, organosulfides, indole-3-carbinol and more…). The CDC (Centers for Disease Control and Prevention) features ‘Cooking Greens’ as one of their ‘Fruit and Vegetables of the Month’.² This site is a great resource for nutritional information, recipes and interesting historical information on a wide variety of fruits and vegetables.

A study examining the association between dietary patterns and mental health in early adolescence investigated the effect of leafy green vegetables on behavior.³ The researchers assessed behavior of 14 year old males and females (n=1324 (i.e. 1.324 participants)) in a population-based cohort study using the Child Behavior Checklist (CBCL). The CBCL measures mental health status, with lower scores representing higher mental status/better behavior and higher scores representing poorer mental health status/behavior. Food intake was assessed using a 212-item semi-quantitative food frequency questionnaire (with leafy green vegetables as one of the items). The results showed that lower CBCL scores (i.e. improved behavioral scores) were significantly associated with increased intakes of leafy green vegetables (and fresh fruit). Not surprisingly, those consuming a ‘Western dietary pattern’, with increased intakes of fast foods, red meat and sweets (candies and chocolates) had higher CBCL scores.³

So if you are thinking about including more greens in your diet this year, the following recipe may be of help:

Collard-Green Olive Pesto⁴

(This recipe is an adaption of a recipe found in Gourmet magazine)

• 1 3/4 lb collard greens
• 7 large green olives, pitted (preferably preserved in oil)
• 2 tsp. balsamic vinegar
• 2 garlic cloves, chopped
• 1/3 cup water (you can use any water left from cooking the collards)
• 1/4 tsp cayenne
• 1/4 tsp black pepper
• 1/4-1/2 tsp. salt to taste
• 1/2 cup (at least) extra virgin olive oil
• 1 oz (or about a 1/2 cup) Parmesan cheese (optional)

Sleep is something so many take for granted and yet insomnia affects a large proportion of the population, 22.1% by recent estimates ².  Untreated insomnia can lead to psychiatric disorders such as anxiety and depression and insomnia commonly occurs in those with psychiatric disorders. Treating the underlying psychiatric disorder will generally improve sleep.³ In the long nights at this time of year, those suffering from insomnia often suffer even more. So to offer some solace in the dark, winter nights, let me explain a little about some of the causative and contributing factors to sleeplessness and some tips that will hopefully improve your slumber.

Insomnia can be caused by a number of factors- ranging from organic (caused by physical health conditions such as pain, headaches, GERD (gastroesophageal reflux disease), hyperthyroidism and hot flashes) to nonorganic causes (not caused by physical health complaints, but may be caused by other factors such as: substances (drugs, caffeine, alcohol and some herbs used to improve adrenal function such as Maca), an underlying mental health disorder, stress, environmental disruptions (bright light at night, uncomfortable temperature in the room) and stress.

In insomnia it is important to rule out physical causes to ensure good physical health and appropriate treatment for insomnia. Once physical causes have been ruled out, a comprehensive evaluation of nonorganic causes is necessary to accurately address the causative and contributing factors to nonorganic insomnia.

A number of medications can contribute to insomnia. These include (but are not limited to): SSRIs, stimulants (such as Ritalin), anticonvulsants, thyroid hormones, steroids (prednisone and others), heart and blood pressure medications and decongestants.

Lifestyle factors that can affect sleep include shift-work, exercising late at night, eating dinner late (especially when it is a heavy or rich meal), nicotine or alcohol up to 6 hours prior to bed, bright ambient light, cool temperatures in the evening and lest we forget a noisy environment due to noise outside one’s bedroom…or within it with a snoring partner!

Helpful tools that one can use to do a bit of evaluation on your own include⁴:

-The Epworth Sleepiness Scale to assess the impact of insomnia on your life (available at: http://yoursleep.aasmnet.org/SleepScale.asp) or for adolescents, the

-A Sleep Diary –a useful tool to track the impact of a variety of factors on your sleep. I encourage people to add in a symbol for when they eat (as meal times can affect sleep) and an asterisk for days in which a note about the stress-level of the day or some other is notable factor seems warranted. These notes can be made on a separate page). For a sample` of a sleep diary, see:  http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf.. Check back on my site soon- in the ‘Patient Forms’ section for an elaborated version of the Sleep Diary.

- A Sleep Evaluation- to assess your need to get further medical help – available at: http://yoursleep.aasmnet.org/SleepEval.aspx

And finally, some tips you can try on your own:

• Sleep Hygiene- reserve the bedroom for sleep and sex. Do not watch TV, read, study or eat in bed. Consider before bed rituals such as a warm bath, meditation, listening to relaxing music, reading a good book (but not too good or stimulating!)….and if you can’t fall asleep after giving it a good try (20-30 minutes), get out of bed, stay warm, use only dim light and don’t eat or drink much unless hunger has been keeping you from sleeping. Limit caffeine, alcohol and nicotine intake for up to 6 hours before sleeping. And establish regular sleep and wake times that are consistent each night.

• Chronotherapy- (Includes some of the suggestions above) and limiting screen exposure at night, wearing amber glasses once it is dark outside, a regular sleep-wake schedule, sleep in a dark bedroom and get morning light

• Hydrotherapy- warm (not hot) salt baths prior to bed. Warm baths warm the core and this signals the body to relax and to sleep. Adding aromatherapy (lavender oil is usually a good one to try) can be helpful too.

•  Herbal/Supplemental/Nutritional- a note on Valerian: while this herb can help many with sleep problems, in a small portion of the population, it can have a paradoxical stimulating effect. As with all herbs, herbs for sleep (of which there are many) need to be used wisely to avoid drug interactions and to improve efficacy. There is validity to the warm milk home remedy. Warmed milk or milk alternative (often with a little nutmeg added) is a widely used remedy in Ayurveda to aid sleep. Eating more simply at night, eating lightly cooked foods and including some carbohydrates in your evening meal can often aid sleep. There are also a number of vitamins and minerals that can be of help. Melatonin is often more helpful in establishing and maintaining a regular sleep-wake rhythm than in inducing sleep per se.

And a note of caution, while sleep medicines may be necessary acutely when insomnia is severely impacting one’s daily functioning and safety, they do not cure insomnia, are associated with a number of side effects ⁵ and can adversely affect the quality of one’s sleep and suppress or affect normal dreaming⁶ (which is important for consolidation of memory and to promote psychological awareness and healing).

We spend a third to a half of our life sleeping and there is so much more to be said about sleep. I will be covering it in more depth in future postings and classes. I hope that you have found this post to be helpful. If you suffer from insomnia, please be sure to seek help- it is critical to your mental-emotional and physical health to get good quality rest on a consistent basis.

References:

¹ Thompson, A. & Taylor, N., (Eds.). (2006). Hamlet. (3^rd ed.). London: Arden Shakespeare, 63-64.

² Roth, T.,  Coulouvrat, C., Hajak, G., et al. (2011). Prevalence and perceived health associated with insomnia based on DSM-IV-TR; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition criteria: results from the America Insomnia Survey.  Biol Psychiatr, 69(6), 592-600.

³ The Cleveland Clinic Foundation (2010) .  Health Information. Diseases and Conditions: Sleep and Psychiatric Disorders.  Retrieved from http://my.clevelandclinic.org/disorders/sleep_disorders/hic_sleep_and_psychiatric_disorders.aspx

⁴ American Academy of Sleep Medicine. (2010). Evaluate Your Sleep. Retrieved from http://yoursleep.aasmnet.org/evaluatesleep.aspx

⁵ US Dept. of Health & Human Services. (2012. Mar. 14)*.  Consumer Updates- Side Effects of Sleep Drugs.  Retrieved from http://www.fda.gov/forconsumers/consumerupdates/ucm107757.htm

⁶ Pagel, J.F. & Parnes, B.L. (2001). Medications for the Treatment of Sleep Disorders: An Overview. Primary Care Companion J Clin Psychiatry, 3, 118-125. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181172/pdf/i1523-5998-003-03-0118.pdf

*Post updated with this information after initial posting date

Herbal and natural supplements can induce hypomania or mania in those with bipolar disorder.  St. John’s Wort, SAMe (S-adenosyl methionine) and Omega 3 fatty acids can cause switching in bipolar.^{4,5,6,7,8,9,10}  Ephedra sinica, Rhodiola rosea, Gingko biloba, Ginseng and Inositol are also implicated in antidepressant-induced hypomania/mania.^6,7,10

There is insufficient evidence to support long-term use of antidepressant herbs in bipolar disorder.  Studies with antidepressant medications generally do not support long-term use of antidepressant agents in bipolar disorder. Current recommendations are to use these herbs as adjuvant treatments with mood stabilizers in bipolar disorder.^6,7,8,10  Cautious, selected use of antidepressants, as opposed to routine use, is advised in bipolar disorder.^11,12,13

There are a number of predictors of antidepressant-induced hypomania and mania.  Patients with bipolar I subtype, mixed episodes or past antidepressant-induced hypomania/mania are prone to switching.  Comorbid substance use increases the risk of switching.  Rapid cycling is strongly associated with increased risks of antidepressant-induced hypomania/mania.^2,14

Patients with bipolar disorder are advised to consult a licensed physician to safely use herbal supplements.⁴  Avoid abrupt withdrawal of antidepressant medications and/or herbs.¹⁴  Herbal antidepressants are not recommended in those with a higher likelihood of antidepressant-induced hypomania or mania.

References:

¹Ghaemi SN. Treatment of Rapid-Cycling Bipolar Disorder: Are Antidepressants Mood Destabilizers? Am J Psychiatry 2008;165:300-1.

²Ghaemi SN, Hsu DJ, Soldani F, etal. Antidepressants in bipolar disorder: a case for caution. Bipolar Disord 2003;5:421-33.

³Holma KM, Melartin TK, Holma IA, etal. Predictors for switch from unipolar majord epressive disorder type I or II: a 5-year prospective study. J Clin Psychiatry 2008;69:1267-75.

⁴Nierenberg AA,  Burt T, Matthews J, etal. Mania associated with St. John’s Wort.  Biol Psychiatry 1999;46:1707-8.

⁵Sarris J, Kavanagh DJ, Byrne G. Adjuvant use of nutritional and herbal medicines with antidepressants, mood stabilizers and benzodiazepines.  J Psychiatr Res 2010;44:32-41.

⁶Iovieno N, Dalton ED, Fava M, etal. Second-tier natural antidepressants: Review  and critique.  J Affect Disord 2010; doi:10.1016/j.jad.2010.06.010

⁷Sarris J. Herbal medicines in the treatment of psychiatric disorders: a systematic review. Phytother Res 2007;21:703-16.

⁸Mischoulon D. Updatea nd Critique of Natural Remedies as Antidepressant Treatments. Psychiatr Clin N Am 2007;30:51-68.

⁹Parker G, Gibson NA, Brotchie H, etal. Omega-3 fatty acids and mood disorders. Am J Psychiatry 2006;163:99-978.

¹⁰Andreescu C, Mulsant BH, Emanuel JE. Complementary and alternative medicine in the treatment of bipolar disorder – a review of the evidence. J Affect Disord 2008;110:16-26.

¹¹Ghaemi SN, Goodwin FK. Antidepressants for Bipolar Depression. Am J Psychiatry 2005;162:1545-5.

¹²Ghaemi SN, Ostacher MM, El-Mallakh RS, etal. Antidepressant Discontinuationin Bipolar Depression: A Systematic Treatment Enhancement Program for Bipola rDisorder (STEP-BD) Randomized Clinical Trial of Long-Term Effectiveness and Safety. J Clin Psychiatr 2010;71;372-80.

¹³Viet aE. Cause for caution, case for action.  Bipolar Disord 2003;5:434-5.

¹⁴Goldberg JF. Antidepressants in bipolar disorder: 7 myths and realities. Current Psychiatry 2010;9:41-9.

-Females are more likely to be on antidepressants than males

-Greater than 60% of Americans taking antidepressant medication have been taking it for 2 or more years

-Of those taking antidepressants, fewer than one-third of those taking a single antidepressant and less than half of those on multiple antidepressant medications have been have been to a mental health professional in the past year

-Non-Hispanic white persons are more likely to take antidepressant medications than Mexican-American and Hispanic black persons

More information is available in the report. The report does not seek to explain these findings, but a few questions and concerns that it raises for me are:

-Are females more likely to have hormonal imbalances that can yield depressive symptoms?

-If a significant proportion of those taking antidepressant medications have not been to a mental health professional in the past year, are they really getting the ongoing medical and psychiatric evaluations necessary to properly evaluate, treat and manage their depression?

-How much of this antidepressant use could be decreased if other treatments were tried prior to antidepressant medications (exercise, diet, herbal medicine, homeopathy, stress management, sleep hygiene, psychotherapy)?

-Is the difference in use across ethnicity a result of cultural differences in seeking help and/or the type of treatment sought? Or is it more readily explained by differences in access to care?

-Much more on alternative and adjunctive treatments for depression will be covered in future blogs, newsletters and classes. If you are concerned that you may be experiencing depression, it is important to pursue your treatment options medically, psychologically and psychiatrically. Untreated depression can adversely affect one’s health and the health of one’s relationships.

Pratt LA, Brody DJ, Gu Q. Antidepressant use in persons aged 12 and over: United States, 2005-2008. NCHS data brief, no.76. Hyattsville, MD. National Center for Health Statistics,2011.