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A young boy talks with Tina Cloer, director of the Children’s Bureau, in Indianapolis. The nonprofit shelter takes in children from the state’s Department of Child Services when a suitable foster family can’t be found. Cloer says the average length of stay at the shelter has increased from two days to 10 in 2015. Jake Harper/Side Effects Public Media hide caption

itoggle caption Jake Harper/Side Effects Public Media

Last year, Erin and Isaac Hougland of Indianapolis got certified to become foster parents, with the hope of adopting a baby. Just a few weeks later, they got a call.

An 8-week-old baby needed a home. All they knew was that the boy’s mother was a heroin addict and had left him at the hospital. They were told that because of the drugs, the baby might require some special care. But mostly, he just needed a place to go.

“Both of us were just like, ‘Let’s do it,’ ” says Isaac Hougland. “We wrapped up what we were doing at work and went to the hospital.”

The Houglands’ foster son is part of a new national influx of kids coming into foster care because parents abusing heroin or prescription painkillers can no longer care for them.

A recent report by the federal government shows that, after years of decline, the number of children in foster care is going up again. Roughly 265,000 kids entered foster care last year — the highest number since 2008.

Between September of 2013 and September of 2015, Indiana saw the number of “children in need of services” jump by 40 percent. In more than half of new cases in which children had to be removed from their homes, substance abuse was listed as a reason. As in other states (such as nearby Ohio), officials in Indiana blame heroin and prescription painkillers.

The increase is taxing the child welfare system, officials say. Children of addicts often need special care and counseling, and they often stay in the system longer because it can take months or years for their parents to get clean.

Marilyn Moores, a juvenile court judge in Indianapolis, says many case managers and court employees are feeling overwhelmed with the rising number of child welfare cases they’re seeing. Jake Harper/Side Effects Public Media hide caption

itoggle caption Jake Harper/Side Effects Public Media

“We have more children than we’ve ever had in our system in Indiana,” says Mary Beth Bonaventura, director of the state’s Department of Child Services. “That puts a stress on the staff, a stress and strain on providers.” And it’s increasingly a challenge, she says, “to find and recruit and train qualified foster families.”

If the Houglands hadn’t provided a home for their foster son, he might have ended up at an emergency shelter like the Children’s Bureau, a nonprofit in Indianapolis. The organization takes in kids from the Department of Child Services when a foster family can’t be found quickly.

“Kids come in here 24/7,” says Tina Cloer, who directs the Children’s Bureau. “So we accept kids all day and all night, and we get calls all day and all night.”

The shelter has been full more often this year, she says, as it has become harder to find kids foster homes. Last year, the average stay was just two days — now, it’s 10. “We have kids that have been here as long as 2 [or] 2 1/2 months,” Cloer says.

The large number of cases burdens other parts of the system, too.

Indiana’s Department of Child Services has a burnout problem: It has lost about a quarter of its case managers in the past year.

“I’ve had a case where we’ve had nine case managers on it — in a year,” says Marilyn Moores, a juvenile court judge in Indianapolis. “That’s the far end, but it’s not unusual to have three or four.”

This year, the child services department started a counseling program for employees, in hopes of retaining more case managers. And the state approved the hiring of 230 more people, but finding and training them will take time. Recruiting can be tough, says Bonaventura.

“If you don’t recruit the right people, they’re out the door the minute they realize how stressful and how gut-wrenching this work is,” she says.

Meanwhile, as the number of cases rises, Moores says, the stress continues to mount for everyone involved, including court employees.

“It just reached a point where every system partner involved in this that I’ve talked to in the last week, when I’ve talked to them, at some point they get tears in their eyes,” she says. “They are just overwhelmed.”

After more than a year of waiting, Erin and Isaac Hougland are looking forward to finally adopting their foster son. But it might take a little longer than usual. Adoption paperwork is piling up, too.

This piece comes from Side Effects Public Media, a public radio reporting collaborative that explores the impacts of place, policy and economics on health.

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Sometime around 1907, well before the modern randomized clinical trial was routine, American psychiatrist Henry Cotton began removing decaying teeth from his patients in hopes of curing their mental disorders. If that didn’t work he moved on to more invasive excisions: tonsils, testicles, ovaries and, in some cases, colons.

Cotton was the newly appointed director of the New Jersey State Hospital for the Insane and was acting on a theory proposed by influential Johns Hopkins psychiatrist Adolph Meyer, under whom Cotton had studied, that psychiatric illness is the result of chronic infection. Meyer’s idea was based on observations that patients with high fevers sometimes experience delusions and hallucinations.

Cotton ran with the idea, scalpel in hand.

This 1920 newspaper clipping from The Washington Herald highlights Dr. Henry Cotton’s practice of removing infected teeth to treat mental health problems.

Library of Congress

In 1921 he published a well-received book on the theory called The Defective Delinquent and Insane: the Relation of Focal Infections to Their Causation, Treatment and Prevention. A few years later The New York Times wrote, “eminent physicians and surgeons testified that the New Jersey State Hospital for the Insane was the most progressive institution in the world for the care of the insane, and that the newer method of treating the insane by the removal of focal infection placed the institution in a unique position with respect to hospitals for the mentally ill.” Eventually Cotton opened a hugely successful private practice, catering to the infected molars of Trenton, N.J., high society.

Following his death in 1933, interest in Cotton’s cures waned. His mortality rates hovered at a troubling 45 percent, and in all likelihood his treatments didn’t work. But though his rogue surgeries were dreadfully misguided and disfiguring, a growing body of research suggests that there might be something to his belief that infection – and with it inflammation – is involved in some forms of mental illness.

Symptoms Of Mental And Physical Illness Can Overlap

Late last year Turhan Canli, an associate professor of psychology and radiology at Stony Brook University, published a paper in the journal Biology of Mood and Anxiety Disorders asserting that depression should be thought of as an infectious disease. “Depressed patients act physically sick,” says Canli. “They’re tired, they lose their appetite, they don’t want to get out of bed.” He notes that while Western medicine practitioners tend to focus on the psychological symptoms of depression, in many non-Western cultures patients who would qualify for a depression diagnosis report primarily physical symptoms, in part because of the stigmatization of mental illness.

“The idea that depression is caused simply by changes in serotonin is not panning out. We need to think about other possible causes and treatments for psychiatric disorders,” says Canli.

His assertion that depression results from infection might seem far-fetched, or at least premature, but there are some data to bolster his claim.

Harkening back to Adolph Meyer’s early 20th century theory, Canli notes how certain infections of the brain – perhaps most notably Toxoplasma gondii — can result in emotional disturbances that mimic psychiatric conditions. He also notes that numerous pathogens have been associated with mental illnesses, including Borna disease virus, Epstein-Barr and certain strains of herpes, including varicella zoster, the virus that causes chickenpox and shingles.

Toxoplasma gondii, a parasitic protozoan, afflicts cats and other mammals. Acute toxoplasmosis produces flu-like symptoms and has been linked to behavioral changes in humans. Eye of Science/Science Source hide caption

itoggle caption Eye of Science/Science Source

A Danish study published in JAMA Psychiatry in 2013 looked at the medical records of over three million people and found that any history of hospitalization for infection was associated with a 62 percent increased risk of later developing a mood disorder, including depression and bipolar disorder.

Canli believes that pathogens acting directly on the brain may result in psychiatric symptoms; but also that autoimmune activity — or the body’s immune system attacking itself — triggered by infection may also contribute. The Danish study also reported that a past history of an autoimmune disorder increases the risk of a future mood disorder by 45 percent.

Antibodies Provide A Clue

The idea there could be a relationship between the immune system and brain disease isn’t new. Autoantibodies were reported in schizophrenia patients in the 1930s. Subsequent work has detected antibodies to various neurotransmitter receptors in the brains of psychiatric patients, while a number of brain disorders, including multiple sclerosis, are known to involve abnormal immune system activity. Researchers at the University of Virginia recently identified a previously undiscovered network of vessels directly connecting the brain with the immune system; the authors concluded that an interplay between the two could significantly contribute to certain neurologic and psychiatric conditions.

Both infection and autoimmune activity result in inflammation, our body’s response to harmful stimuli, which in part involves a surge in immune system activity. And it’s thought by many in the psychiatric research community that inflammation is somehow involved in depression and perhaps other mental illnesses.

Multiple studies have linked depression with elevated markers of inflammation, including two analyses from 2010 and 2012 that collectively reviewed data from 53 studies, as well as several post-mortem studies. A large body of related research confirms that autoimmune and inflammatory activity in the brain is linked with psychiatric symptoms.

Still, for the most part the research so far finds associations but doesn’t prove cause and effect between inflammation and mental health issues. The apparent links could be a matter of chance or there might be some another factor that hasn’t been identified.

Dr. Roger McIntyre, a professor of psychiatry and pharmacology at the University of Toronto, tells Shots that he believes an upset in the “immune-inflammatory system” is at the core of mental illness and that psychiatric disorders might be an unfortunate cost of our powerful immune defenses. “Throughout evolution our enemy up until vaccines and antibiotics were developed was infection,” he says, “Our immune system evolved to fight infections so we could survive and pass our genes to the next generation. However our immune-inflammatory system doesn’t distinguish between what’s provoking it.” McIntyre explains how stressors of any kind – physical or sexual abuse, sleep deprivation, grief – can activate our immune alarms. “For reasons other than fighting infection our immune-inflammatory response can stay activated for weeks, months or years and result in collateral damage,” he says.

Unlike Canli, McIntyre implicates inflammation in general, not exclusively inflammation caused by infection or direct effects of infection itself, as a major contributor to mental maladies. “It’s unlikely that most people with a mental illness have it as a result of infection,” he says, “But it would be reasonable to hypothesize that a subpopulation of people with depression or bipolar disorder or schizophrenia ended up that way because an infection activated their immune-inflammatory system.” McIntyre says that infection, particularly in the womb, could work in concert with genetics, psychosocial factors and our diet and microbiome to influence immune and inflammatory activity and, in turn, our risk of psychiatric disease.

Trying Drugs Against Inflammation For Mental Illness

The idea that inflammation – whether stirred up by infection or other factors — contributes to or causes mental illness comes with caveats, at least in terms of potential treatments. Trials testing anti-inflammatory drugs have been overall mixed or underwhelming.

A recent meta-analysis reported that supplementing SSRIs like Prozac with regular low-dose aspirin use is associated with a reduced risk of depression and ibuprofen supplementation is linked with lower chances of obtaining psychiatric care. However concomitant treatment with SSRIs and diclofenac or celecoxib – two other anti-inflammatories often used to treat arthritis – was associated with increased risk of needing hospital care due to psychiatric symptoms.

A 2013 study explored the antidepressant potential of Remicade, an drug used in rheumatoid arthritis. Overall, three infusions of the medication were found to be no more effective than a placebo, but patients whose blood had higher levels of an inflammatory marker called C-reactive protein did experience modest benefit.

“The truth of the matter is that there is probably a subset of people who get depressed in response to inflammation,” says lead author Dr. Charles Raison, a psychiatry professor at the University of Arizona. “Maybe their bodies generate more inflammation, or maybe they’re more sensitive to it.”

How infection and other causes of inflammation and overly-aggressive immune activity may contribute to depression and other mental illnesses – and whether or not it’s actually depression driving the inflammation — is still being investigated, and likely will be for some time. But plenty of leading psychiatrists agree that the search for alternative pathologic explanations and treatments for psychiatric disorders is could help jump-start the field.

“I’m not convinced that anti-inflammatory strategies are going to turn out to be the most powerful treatments around,” cautions Raison. “But I think if we really want to understand depression, we definitely have to understand how the immune system talks to the brain. I just don’t think we’ve identified immune-based or anti-inflammatory treatments yet that are going to have big effects in depression.”

But the University of Toronto’s McIntyre has a slightly brighter outlook. “Is depression due to infection, or is it due to something else?” he asks. “The answer is yes and yes. The bottom line is inflammation appears to contribute to depression, and we have interventions to address this.”

McIntyre notes that while the science of psychiatry has a long way to go, and that these interventions haven’t been proved effective, numerous approaches with minimal side effects exist that appear to be generally anti-inflammatory, including exercise, meditation and healthy sleep habits.

He also finds promise in the work of his colleague: “Like most cases in medicine, Charles Raison showed that anti-inflammatory approaches may benefit some people with depression, but not everybody. If you try on your friend’s eyeglasses, chances are they won’t help your vision very much.”

Bret Stetka is a writer based in New York and an editorial director at Medscape. His work has appeared in Wired and Scientific American, and on The Atlantic.com. He graduated from the University of Virginia School of Medicine in 2005. He’s also on Twitter: @BretStetka

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Oviea Akpotaire and Jeffrey Okonye put in long days working with patients at the veterans’ hospital in south Dallas as fourth-year medical students at the University of Texas Southwestern.

They’re in a class of 237 people and they’re two of only five black men in their class.

“I knew the ones above us, below us,” Okonye says. “We all kind of know each other. It’s comforting to see another person that looks like you.”

While more black men graduated from college over the past few decades, the number of black men applying to medical school has dropped. In 1978, 1,410 black men applied to medical school and 542 ended up enrolling. In 2014, both those numbers were down — 1,337 applied and 515 enrolled.

Those figures come from a report from the Association of American Medical Colleges. Every other minority group — including Asians and Hispanics — saw growth in applicants. There was also an uptick in applications by black women.

Enrollment statistics for 2015 are just out and they show a modest gain of 8 percent more black men entering medical school over the year before.

“This is a positive sign,” says Marc Nivet, AAMC’s chief diversity officer, “but it does not change the fact that for 35 years the number has been trending poorly.”

“I was really surprised,” says Akpotaire, who is studying internal medicine. “I sent [the study] to my mom and dad immediately. You would think the conditions would be a lot different than they were in 1978.”

Diversity among doctors is important for patient health. People are more likely to follow doctors’ directions on things like medication or exercise if they can identify with them.

Dr. Dale Okorodudu, a third-year pulmonary and critical care fellow at UT Southwestern, says making cultural connections can make a big difference.

“If you can relate to [patients], it’s a lot easier for them to feel at home and comfortable with you,” he says.

Okorodudu wrote a blog post about an experience at Parkland Hospital that stuck with him. He was walking down the hallway on the 10th floor when a black man stopped him:

“It’s good to see you brother!” I had never met this man, but I knew exactly what he was talking about. With a large smile on his face and a look of pride, he extended his arm to give me a handshake. “There aren’t too many of us doing what you do. I’m glad we got some representation in here.”

For years, Okorodudu has been trying to figure out why so few black men go into medicine. His conclusion: the lack of role models.

“If you’re a black male, let’s say you’re growing up in an inner-city neighborhood,” he says. “There’s so many things directly in front of you that you have the option to go into.”

The options range from music and sports to small business and church, Okorodudu says those professions are visible and present in the lives of young African-American boys. “But when you talk about the medical workforce, none of us are directly there in front of them,” he says.

Okorodudu decided to become a doctor when he was 18. A year from now, when he’s done with his fellowship, he’ll be 32.

Med student Jeffrey Okonye points out that for students like him, who embraced math and science, there are much faster ways to “make it.”

“A lot of friends of mine, black males, are engineers,” Okonye says. “They go to school for four years. They have a job, great pay, even had internships in undergrad I was highly jealous of. Whereas my route, four years undergrad, then another four years of school, and then another X amount of training after that.”

So why did he take the longer route?

“It’s hard to describe the feeling you get when you make someone actually feel better,” Okonye says. “When you can see them go from one state to another and recognize that you were a part of literally changing this person’s life.”

A desire to care for others isn’t the only thing that Okonye, Akpotaire and Okorodudu have in common. All three have had doctors or nurses in their families. And all three are the children of immigrants from Nigeria. Okorodudu says that means the group of black men who are applying to medical school now is very different from the group in 1978.

“In 1978, those people we’re looking at, a lot of them were probably black American males” whose families had been in this country for generations, he says. Today’s black medical school students may be more recent immigrants from Nigeria or the Caribbean, he says. “So if we broke it down that way, that factoid is actually even more alarming.”

The AAMC report suggests how to restock the doctor pipeline. Among the ideas: create more mentoring programs, expand financial aid options, and persuade medical schools to put less emphasis on standardized tests scores like the MCATs.

Okorodudu is trying to help with an online service called DiverseMedicine. Users connect with mentors on chat or video.

Sometimes, he says, the key to getting kids interested is simply seeing a black man in a white coat.

This story is part of a reporting partnership that includes NPR, local member stations and Kaiser Health News.

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