Tuesday, January 19, 2010

No Condolence Letter For Families of Soldiers Who Commit Suicide

When a soldier is killed while in the military service the President writes a condolence letter to the family. However, if a soldier is psychologically injured and then commits suicide, there is no Presidential letter of condolence. There is apparently an unwritten policy that this does not include families of soldiers who have committed suicide.

It is easy to imagine how hurtful that must be for families who are burying a loved one who came back from war with psychological problems and then committed suicide or perhaps did it overseas.

One Such Family
After my blog on this subject appeared in PsychiatryTalk.com

I received a comment from Gregg Keesling the father of one such soldier and then had a correspondence with him. His story was also written up in the NY Times.

His 25-year-old son Chancellor served two deployments . He committed suicide in Iraq after sending his parents an email telling them of his decision. He said that “ military investigations demonstrated, our son Chancellor was a good soldier. He succumbed to an illness as much as someone who dies in the war theater from food poisoning or infection, and we believe that the President should send condolences and express the country’s appreciation of our family’s sacrifice.”

A spokesperson for President Obama said that the policy in regard to who should receive a letter of condolence is currently undergoing a review.

What Reasons Are Given For Opposing A Letter of Condolence ?
I have tried to understand why anyone would advocate that the President should not express condolence to families such as the Keeslings I heard one view that many soldiers would feel that their comrades combat death would be demeaned if the families of soldiers who suicided were given an equal letter of condolence. Another view is that treating suicide the same as other war deaths might encourage mentally frail soldiers to take their lives by making the act seem honorable.

I believe these ideas are misguided and resurrect the stigmatization of mental illness. Soldiers cannot will themselves to avoid these emotional states anymore than a soldier can avoid a bullet or an explosive device. Once you are in a combat zone, you are vulnerable to injury. I know of no evidence that people on the verge of suicide would be driven to it because their family would get a letter of condolence.

They Are All Heroes
If a soldier in Iraq were accidentally killed in a car accident, would his death be any less deserving a letter of condolence than a soldier who was killed in an enemy ambush? Would the family be any less deserving of the letter if the soldier made a tactical error leading to his death as compared to someone who bravely fell on a grenade to save others lives? Similarly, would you compare a soldier who faced many horrific combat situations and developed PTSD with another soldier who became severely depressed shortly after arrival in the combat zone if both ended up having intolerable suicidal feelings, which led to their death? I don’t believe that we judge some soldier’s deaths as being more worthy than others.

Yes, we do give out medals for unusual acts of bravery but this in no way diminishes the sacrifices that others have made.
Every soldier has volunteered and knows that he or she could be exposed to combat. For this they deserve our thanks and when they make the supreme sacrifice, their families deserve a letter of condolence.

Recent Actions To Attempt to Influence The President
On December 23rd a bipartisan coalition of 44 House members initiated by Reps Patrick Kennedy and Dan Burton sent a letter to President Obama. They wrote “ By overturning this policy on letters of condolence to the families of suicide victims you can send a strong signal that you will not tolerate a culture in our Armed Forces that discriminates against those with a mental illness.”

The American Foundation for Suicide Prevention in a letter to the President on January 5th wrote “We agree with members of Congress that you can send a strong signal that you will not tolerate a culture in our military services that discriminates against those with mental illness. Please Mr. President, overturn this policy as soon as possible.”

On January 7th Mental Health American announced the adoption of a position requesting the President revoke the policy of not writing condolence letters to families of soldiers who have committed suicide They also started an online petition on Facebook.

Write to the President Now
I continue to urge anyone concerned about this issue to write to the President Those who are mental health professionals should state this and explain your views based on your understanding of mental illness. The email address to write the President is http://whitehouse.gov/contact

Michael Blumenfield, MD

Dr Blumenfield is The Sidney E. Frank Distinguished Professor Emeritus of Psychiatry and Behavioral Sciences at New York Medical College. He is a recent Past Speaker of the Assembly of the American Psychiatric Association. Dr Blumenfield lives and practices in Woodland Hills, CA, where he also writes a weekly blog, PsychiatryTalk.com.

Read more!

Tuesday, January 12, 2010

Western Psychiatric Imperialism, or Something Else?

In a very long essay in the Sunday (1/10/10) New York Times Magazine, entitled, “The Americanization of Mental Illness,” Ethan Watters suggests that a kind of psychiatric-cultural imperialism has been foisted on other countries and cultures by “the West.”

Specifically, Watters claims that, “For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world…. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures.”

Watters claims, for example, that as the general public and mental health professionals in Hong Kong “…came to understand the American diagnosis of anorexia,, the presentation of the illness in Hong Kong actually became more “virulent.”

Though the Watters thesis has its merits, it is also glib and simplistic in many of its assumptions and conclusions. To be fair: Watters rightly calls attention to the ways that culture and ethnicity can shape both the diagnosis and expression of psychiatric conditions and symptoms. But this is hardly news to psychiatrists: the late Dr Ari Kiev advanced much the same thesis in his 1972 book, Transcultural Psychiatry.

Watters’ more controversial claim is that the exportation of American psychiatric nosology and “biomedical ideas” has changed the way symptoms are diagnosed and expressed in some other cultures. But this claim is very hard to validate. The “American” diagnostic system is, in the first place, not terribly different from the World Health Organization’s International Classification of Disease (ICD), whose descriptions of “mental and behavioral disorders” evolved almost contemporaneously with those of the last two DSMs. It would be very hard to tease out the cross- cultural influence of the DSM classification from that of the ICD, over the past 30 years. More important, Watters fails to consider alternative explanations for his “findings”; for example, rising rates of DSM-type anorexia nervosa in Hong Kong could be due largely to increased recognition of a long-standing, indigenous disorder that heretofore had not been fully appreciated by Chinese clinicians.

An example from American history helps make the point. Many of the basic symptoms of post-traumatic stress disorder (PTSD) have been recognized for centuries—at least since the U.S. Civil War, and probably much earlier—and have gone by various names, such as “soldier’s heart,” “combat fatigue," “shell-shock,” etc. But it took the efforts of troops returning from the Vietnam War to “push” psychiatry toward recognition of PTSD as a bona fide disorder. Understandably, apparent PTSD prevalence rates have soared since the diagnosis entered American nosology in 1980, with the advent of DSM-III. But it is entirely possible that the actual prevalence of PTSD symptoms in the U.S. has not changed markedly over many generations.

So, to return to Mr. Watters’ thesis: it would not be surprising to find that, as clinicians in other cultures began to familiarize themselves with DSM or ICD psychiatric disease criteria, the apparent prevalence rates of certain psychiatric conditions increased in those countries. It is quite another thing to imply that the actual prevalence of these conditions has increased—and that their morphology has changed--as a result of Western influences. Yet Watters seems to imply just this, when he asserts that

“…a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These [Western-based] symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.”

We would need several generations of very sophisticated epidemiological studies, carried out using identical diagnostic criteria, to substantiate this “contagion-replacement” hypothesis. Anecdotal data, such as those presented in the Watters article, are inadequate. But even if Watters is correct, his claims do not answer the fundamental medical-ethical question: will adopting “Western” diagnostic criteria ultimately lead to a net reduction in suffering, and a net increase in well-being, in other cultures? If, after careful systematic study, the answer to this question turns out to be no, our Western paradigms will have failed. If the answer turns out to be yes, we may conclude that we have been exporting a very valuable commodity.

Ronald Pies, MD

Dr. Pies would like to acknowledge both Rakesh Jain MD and Sandy Naiman for inspiring this blog. Read more!

Wednesday, January 6, 2010

Why Psychiatrists Should go Green

I don’t know how many psychiatrists paid much attention to the climate-change conference in Copenhagen last month, but I came away convinced they need our help. Here’s why. Given the scientific consensus that human behavior is the major cause of the planet’s undesired warming, who better to understand the roots, manifestations, repercussions, and treatment of that behavior?

But like much of our work, fostering change in this realm will not come easy. The industrialization that led to excessive use of the damaging fossil fuels fulfilled some of our basic psychological needs like safety, security, and survival. Once used to such lifestyles, they are hard to give up, and also come to be desired by poorer people. Usually, one has to receive some replacement reward to willingly want to try a change.

Moreover, the prediction that the major risks of climate-change are decades away naturally contributes to our passivity. We are equipped with a rapid fight-or-flight response to perceived immediate danger, which early humans faced day by day, but our brain has not evolved any automatic responses to future risks. Freud seemed to translate this biological process into psychodynamic understanding. The psychological defense mechanism of denial is helpful when we need to set priorities or to ignore something too painful at the moment. It is maladaptive when it leads to behavior that endangers us. Such maladaptive behavior as it relates to climate-change might be best illustrated by the legendary experiment of the frog and boiling water. If you throw a frog into boiling water, it will jump right out. However, if you put it in warm water and gradually increase the temperature to boiling, the frog will stay and cook to death. Who knows? If Freud were still alive, this experiment might be enough for him to revive his abandoned concept of a death instinct.

Maybe these natural tendencies contributed to some of the terminology that we use, which is not likely to evoke a sense of danger. The use of “warming”, as in the term of global warming, seems like psychological milquetoast. In fact, for people living in colder climates, like my Wisconsin, where the wind-chill as I write is minus 10 degrees, that terminology can paradoxically sound psychologically welcoming. Similarly for the terminology of the conference, climate-“change.” Such change can be perceived as potentially beneficial or not.

Unfortunately, the psychological repercussions of this challenge are slowly emerging. Among them are:

-Heat waves are associated with more alcohol and substance abuse.
-Just an average increase of 1 degree F seems to increase the risk of aggressive and violent behavior in warm climates, especially in the inner city and places of poor resources.
-Loss of your comfortable environment often causes a dangerous variation of grief, called solastalgia.
-So-called “climate refugees” have high rates of Posttraumatic Stress Disorders, often complicated by “cultural bereavement”.

How, then, can we help? As usual, we could treat the panic anxiety, PTSD, paralyzing guilt, and malignant narcissism as it emerges, but this might well be too little, too late. Up to now, most psychiatrists have not paid much attention to this problem, probably for the same sort of reasons as the rest of the public. Even our organizational Disaster Response Teams are prepared for responding to acute disaster, but not to the more chronic and slowly developing ones. For one thing, then, we can expand the charge of such teams accordingly.

For another thing, we can recommend better terminology to evoke an appropriate degree of anxiety and fear. Akin to the frog experiment, how about “global boiling”? Akin to mental instability, how about “climate instability”?

Even though psychiatrists are not yet known to be desired role models, we can model environmentally helpful behavior in our offices and personal life. We can use subliminal messages, such as wearing more green, the symbolic color of environmentalism. Why, I’ve gone so far as to wear the costume of the Jolly Green Giant of vegetable marketing fame to become “The Jolly Green Giant of Psychiatry,” which- - believe it or not - - actually won first place at a benefit costume contest.


The Oddest Couple ? The Jolly Green Giant of Psychiatry: He'll Analyze Climate Instability and The Little Red Riding Hood(lum) of Song and Dance: She'll Steal Your Heart and Soul. . .

The couple (Steven Moffic, MD and Rusti Moffic) is available for multimedia presentations in going green. . .

H. Steven Moffic, MD

“We now need to hear more from . . . people who understand the wellsprings of human behavior and values”.

-Dean Speth (Yale’s Green Experiment, Yale Alumni Magazine, November, 2007). Read more!