Psyche, Science, and Society

Psychiatry fights over DSM

While psychology is riven with conflicts over the profession’s role in interrogations, torture, and detainee abuse, and anthropology is fighting over military (mis)use of Human Terrain Systems counterinsurgency efforts, psychiatry, too, has its civil war. In the case of psychiatry, the battle is over the revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), now in edition IV. The lead psychiatrists for the third and fourth editions are among the fiercest critics of the process for developing the fifth edition.

While the controversy may seem arcane, it has major real world consequences. If, as expected, the DSM radically expands the number and scope of “mental disorders,” it will likely lead to a major increase in the number of people receiving psychotropic medications. For DSM is not really about understanding mental or emotional problems so much as it is about identifying target conditions for medications. While medications have their uses in treatment of mental or emotional problems, they are far from the only, and should often not be the primary approach to treatment.

While the National Institutes of Health usually requires psychotherapy researchers to study therapy for identifiable DSM conditions, there is really little evidence that the DSM way of carving up emotional problems is relevant to psychosocial treatments. For psychotherapies deal with emotional or interpersonal conflicts, (maladaptive” thoughts, problematic coping strategies, or dysfunctional behavior patterns and the like. None of these therapy targets map onto DSM categories in any systematic way. Yet, therapists are often required to assign DSM diagnoses to their patients.

Thus, the DSM is part of an imperial effort by psychiatry to make medication the dominant treatment modality for anyone experiencing problems in living. Unfortunately, the American Psychological Association, which might be expected to lead the opposition to this medicalization of human problems is more interested in helping their members get a share of this lucrative business. The psychological association has made getting psychologists the right to prescribe psychotropic drugs their #1 legislative priority. If the succeed, it is likely that psychologists, like psychiatrists, will find prescribing medications much more lucrative than listening to patients, and psychosocial approaches will be further marginalized.

New Scientist covers the controversy in a new article and recomends doing away with the lucrative DSM books altogether in an accompanying editorial:

Psychiatry’s civil war

By Peter Aldhous

Since this article was first posted, the American Psychiatric Association has announced that the publication of DSM-V will be delayed until May 2013. “Extending the timeline will allow more time for public review, field trials and revisions,” says APA president Alan Schatzberg.

When doctors disagree with each other, they usually couch their criticisms in careful, measured language. In the past few months, however, open conflict has broken out among the upper echelons of US psychiatry. The focus of discord is a volume called the Diagnostic and Statistical Manual of Mental Disorders, or DSM, which psychiatrists turn to when diagnosing the distressed individuals who turn up at their offices seeking help. Regularly referred to as the profession’s bible, the DSM is in the midst of a major rewrite, and feelings are running high.

Two eminent retired psychiatrists are warning that the revision process is fatally flawed. They say the new manual, to be known as DSM-V, will extend definitions of mental illnesses so broadly that tens of millions of people will be given unnecessary and risky drugs. Leaders of the American Psychiatric Association (APA), which publishes the manual, have shot back, accusing the pair of being motivated by their own financial interests – a charge they deny. The row is set to come to a head next month when the proposed changes will be published online. For a profession that exists to soothe human troubles, it’s incendiary stuff.

Psychiatry suffers in comparison with other areas of medicine, as diseases of the mind are on the whole less well understood than those of the body. We have, as yet, only glimpses into the fundamental causes of the common mental illnesses, and there are no biological tests to diagnose them. This means conditions such as depression, schizophrenia and personality disorders remain difficult to diagnose with precision. Doctors can only question people about their state of mind and observe their behaviour, classifying illness according to the most obvious symptoms.

First published in 1952, the DSM has its origins in a book used by the US military to determine if recruits were mentally fit for combat. The difficulty of separating mental disorders from normal variation in behaviour made it controversial from the start. Over the years, the book’s influence has grown, and today it is used by doctors across the globe.

The wording used in the DSM has a significance that goes far beyond questions of semantics. The diagnoses it enshrines affect what treatments people receive, and whether health insurers will fund them. They can also exacerbate social stigmas and may even be used to deem an individual such a grave danger to society that they are locked up.

Some of the most acrimonious arguments stem from worries about the pharmaceutical industry’s influence over psychiatry. This has led to the spotlight being turned on the financial ties of those in charge of revising the manual, and has made any diagnostic changes that could expand the use of drugs especially controversial. “I think the DSM represents a lightning rod for all kinds of groups,” says David Kupfer of the University of Pittsburgh, Pennsylvania, who heads the task force appointed by the APA to produce the revised manual.

Few would claim that the DSM’s current version is perfect. With each revision, the number of conditions it defines has swelled, many surrounded by bewildering lists of symptoms that must be checked to assign a diagnosis. Using current DSM checklists, for example, 114 different combinations of symptoms can lead to a diagnosis of schizophrenia. At the same time, many patients prove hard to fit into the framework.

One aim of the work groups compiling DSM-V is to cut through this chaos. They are streamlining diagnoses by removing various subtypes of schizophrenia, for example, and intend to address the confusion created by the fact that many people with one condition meet criteria for other disorders as well. The DSM-V task force is expected to propose a series of “dimensions” to be considered with a patient’s main diagnosis. So as well as deciding whether someone has, say, bipolar disorder, doctors would determine whether they are suffering from problems such as anxiety and sleeping disturbances, and assess them on a simple scale of severity.

Grandiose claims

This is widely seen as a first step towards a future in which psychiatric diagnosis has a more scientific base, where sprawling checklists of symptoms are replaced by sliding-scale measurements of the underlying determinants of mental health. Yet critics worry that even a limited embrace of this “dimensional” approach is running ahead of the science. Until we understand more about the biological basis of psychiatric disease, this approach will not be helpful, they say.

Some of the harshest criticisms have come from those who led previous revisions of the DSM, in 1980 and 1994. In July, Robert Spitzer and Allen Frances, both now retired, wrote a stinging letter to the APA, accusing it of planning unworkable changes and making grandiose claims. In a separate editorial in the magazine Psychiatric Times, Frances complained that most of the authors are university-based researchers who are cut off from typical doctors and patients.

Spitzer and Frances also criticise the fact that members of the various DSM-V work groups have had to sign confidentiality agreements. “The main problem is that we don’t know what they’re doing,” says Spitzer. The APA says the confidentiality agreements are to stop the manual’s authors writing their own diagnostic handbooks alongside the official manual. Kupfer points out that discussion does go on: work groups proposing major changes debate their ideas in papers and at meetings. “We’ve done everything we can to encourage it,” he says.

Another focus for Spitzer and Frances’s concern is the suggestion that DSM-V could include new categories to capture milder forms of illnesses such as schizophrenia, depression and dementia. “The result would be a wholesale… medicalization of normality that will lead to a deluge of unneeded medication,” Frances said in his editorial.

For example, one work group is considering whether it is possible to catch people in the early stages of schizophrenia or other psychotic illnesses before they have their first full-blown psychotic episode (Schizophrenia Bulletin, vol 35, p 841). Some doctors prescribe antipsychotic drugs at this early stage in the hope of stopping the illness from progressing.

Libido loss

These medicines can have serious side effects, such as loss of libido, weight gain and distressing tremors and spasms, so no one would want to take them without good reason. Yet it’s hard to separate distressed people who will go on to develop a psychotic disorder from the “false positives” – those who will recover or develop a different illness. The available evidence suggests that only about 30 per cent of people identified as being at risk of psychosis will go on to develop it within two years.

Nevertheless, William Carpenter, a psychiatrist at the University of Maryland in Baltimore who chairs the DSM-V work group on psychosis, believes the needs of the “true positives” are so great that adding a diagnostic category to cover “psychosis risk” would, on balance, be a good thing. Frances brands this proposed diagnosis as “the most worrisome suggestion entertained”.

Given the controversy, psychosis risk may not make it into the DSM proper, and may instead appear in the appendix, as a condition needing more research. But even that designation might boost prescribing.

Frances and Spitzer are not the only ones with concerns, and there are other flashpoints (see “Hebephilia”, “Transgendered” and “Bereavement”). In March, Jane Costello of Duke University in Durham, North Carolina, resigned from the work group on disorders in childhood and adolescence, worried about what she saw as a lack of scientific rigour across the whole DSM revision. “I felt that there was not enough empirical work being achieved or planned,” she says.

The disputes are getting ugly. Senior APA figures have even suggested that Spitzer and Frances are motivated by a desire to safeguard their flow of royalties from clinical guides linked to the current DSM. “The fact that Dr. Frances was informed… that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique,” leading APA figures said in a response to Frances’s editorial.

Spitzer and Frances reject this charge. “To suggest that I have no concern other than the royalties is a little absurd,” says Spitzer. “My annual royalties from DSM-IV related books are $10,000 per year,” notes Frances. “These have nothing to do with concerns I expressed.”

Attention has also turned to the financial interests of those working on DSM-V. The APA has ruled that members of the task force and work groups may not receive more than $10,000 per year from industry while working on DSM-V, and must keep their stock holdings below $50,000. This doesn’t satisfy Lisa Cosgrove of the University of Massachusetts, Boston, who studies financial conflicts in psychiatry (New Scientist, 29 April 2006, p 14). She notes that the APA’s ruling places no limit on industry research grants, and has found that the proportion of DSM-V panel members who have industry links is exactly the same as it was for DSM-IV, at 56 per cent (The New England Journal of Medicine, vol 360, p 2035).

The final version of DSM-V is scheduled to be published in 2012, but given the level of controversy and the need to test whether psychiatrists can reliably use the proposed diagnoses, that date seems certain to slip.

For now, there is an uneasy ceasefire, but next month the work groups will post their proposed changes on the APA’s website. Stand by for renewed hostilities.

December 13th, 2009

The “Ethical Interrogation”: The Myth of Michael Gelles and the al-Qahtani Interrogation

Several public accounts of abusive interrogations at Guantanamo have praised psychologist Dr. Michael Gelles for his opposition to these abuses. Similarly, the American Psychological Association (APA) has repeatedly pointed to actions of Dr. Gelles to instantiate their claim that psychologists played a crucial role in opposing abuses and protecting detainees. Gelles also has been a regular public presence, discussing the errors at Guantanamo while advocating for the APA’s “policy of participation” in interrogations. The APA policy encourages psychologists to aid interrogations to keep them “safe, legal, ethical, and effective.” But a recently released Defense Department document challenges Dr. Gelles’s role as an exemplar of psychological ethics in interrogations.

As reported by Bill Dedman, Phillipe Sands, and Jane Mayer, Gelles objected to the “harsh” interrogation tactics being used at Guantanamo. In particular, he strenuously objected to the plans to “reverse engineer” the tactics used by the military’s Survival, Evasion, Resistance, and Escape (SERE) program to inculcate strategies for resistance to torture in US service members at high risk for capture.

In November 2002, the military planned to use these SERE-based techniques on prisoner 063, Mohammed al Qahtani, one of several US captives dubbed the “20th hijacker.” Gelles and colleagues from the Criminal Investigative Task Force (CITF), the FBI, and other agencies proposed an alternative interrogation plan for al Qahtani, one that did not involve use of SERE techniques. This plan was rejected. Instead, al-Qahtani was subjected to an interrogation that met the legal definition of “torture,” according to Bush Administration appointee Susan Crawford, convener of the Guantanamo Military Commissions. [Phillipe Sands detailed the development of the al-Qahtani torture plan in his book, The Torture Team, an extract from which was published in Vanity Fair. Sands also describes the alternate CITF/FBI plan as written by "Gelles' team" (p. 130).] Gelles reported his concerns regarding use of SERE techniques and the al-Qahtani interrogation up the chain of command, leading Navy General Counsel Alberto Mora to protest and force at least temporary change in official interrogation policy in early 2003.

A few weeks ago, in response to an ACLU’s years-long Freedom of Information Act Request, the alternative interrogation plan for al-Qahtani was quietly released, apparently unnoticed between other documents on FBI and CITF concerns about Guantanamo practices. According to the alternative plan document, it was drafted:

“by representatives of the FBI’s Behavioral Analysis Unit (BAU), and behavioral specialists, psychiatrists and psychologists with the Criminal Investigation Task Force (ClTF).”

Given the prominent roles of mental health professionals in its drafting, the alternative “rapport-based” plan should be examined for consistency with Gelles’ and the other authors’ ethical responsibilities as psychologists and psychiatrists.

At the time the plan was written, on November 22, 2002, al-Qahtani had been in isolation for three months and was exhibiting signs of severe mental deterioration to the extent of psychosis. An FBI agent described this deterioration in a report to headquarters:

“In September or October of 2002 FBI agents observed that a canine was used in an aggressive manner to intimidate detainee __ after he had been subjected to intense isolation for over three months. During that time period, __ was totally isolated (with the exception of occasional interrogations) in a cell that was always flooded with light. By late November, the detainee was evidencing behavior consistent with extreme psychological trauma (talking to non-existent people, reporting hearing voices, crouching in the corner of a cell covered with a sheet for hours on end).”

Gelles and the other authors on the CITF/FBI interrogation plan also noticed his psychological distress:

“#63’s behavior has changed significantly during his three months of isolation. He spends much of his day covered by a sheet, either crouched in the corner of his cell or hunched on his knees on top of his bed. These behaviors appear to be unrelated to his praying activities. His cell has no exterior windows, and because it is continuously lit, he is prevented from orientating himself as to time of day. Recently, he was observed by a hidden video camera having conversations with non-existent people. During his last interview on 11/17/02, he reported hearing unusual sounds which he believes are evil spirits, including Satan.”

After discussing whether al-Qahtani was faking his symptoms, without coming to a conclusion, the interrogation plan proposed exploiting al-Qahtani’s distress from his prolonged isolation:

“Although we are uncertain as to his mental status and recommend a mental evaluation be conducted, there is little doubt that #63 is hungry for human interaction. Our plan is designed to exploit this need and to create an environment in which it [is] easier for #63 to please the interviewer with whom he has come to have complete trust and dependence thus developing a motivation to be forthright and cooperative in providing reliable information.”

In order to exploit this hunger for human contact, the CITF/FBI plan recommended that he be kept in continued isolation for up to an additional year:

“The long-term strategy would be to create an environment in which total dependence and trust between #63 and the interviewer is established at its own pace. Such a plan should be given up to a year to complete although the actual time may be considerably shorter depending on how events unfold.”

Al-Qahtani’s hunger for human contact would be exploited by making his interrogator the only person he saw over this year:

“To help foster an environment conducive to the establishment of dependence and trust, we propose that the interviewer initially meet with #63 every other day. This should be his only contact with other people, and we believe he will anxiously look forward to these meetings.”

It was recommended that al-Qahtani be periodically subjected to additional stresses so that his interrogator could become his savior:

“Built into this plan will be periodic stressors such as the stripping of certain items of comfort from him by guards, such as the removal of his mirror or the issuance of a sheet, half the size of the one he likes to drape around himself. These and other stressors will be carefully and subtly introduced not by the interrogator, but by guards. We believe that #63 will likely look to his only human contact, his interviewer, in an attempt to gain help. The interviewer status as a caregiver and problem-solver will thus be increased…. [D]emands by #63 for restoration of things taken from him should be honored slowly so as to create the impression that the interviewer can ultimately help him although not necessarily quickly or with ease.”

This plan for prolonged manipulation to develop al-Qahtani’s complete dependency might or might not be ethical as an interrogation strategy. However, former police investigator and veteran Army counterintelligence operative David DeBatto, who has supervised many hundreds of interrogations, disparaged the use of isolation in the CITF/FBI interrogation plan for al Qahtani (personal communication, November 28, 2009):

“That [the initial three-months isolation] is an excessively long time and on the face of it, violates the UCMJ [Uniform Code of Military Justice] and international law. Two major problems I have with this is first, solitary is a punishment reserved for the worst kind of behavior by inmates in a prison, not for refusing to answer questions. Second, it is the worst possible way to interrogate anyone and will almost always produce negative results.”

At a minimum, there is no question that the participation of psychologists and psychiatrists in the development of this interrogation plan led to the recommendation of strategies that would be likely to cause severe psychological distress and clearly violated psychological and psychiatric ethics.

Prolonged isolation frequently causes severe emotional distress, including psychotic symptoms identical to those appearing in al-Qahtani, such as hearing non-existent voices and talking to non-existent people. Physicians for Human Rights summed up the psychological and psychiatric evidence regarding the harmful effects of isolation or “solitary confinement” in their Leave No Marks report on the US use of psychological torture:

“Findings from clinical research performed by prominent psychologists such as Dr. Stuart Grassian and Dr. Craig Haney, highlight the destructive impact of solitary confinement. Effects include depression, anxiety, difficulties with concentration and memory, hypersensitivity to external stimuli, hallucinations and perceptual distortions, paranoia, suicidal thoughts and behavior, and problems with impulse control.

“According to Dr. Haney many of the negative effects of solitary confinement are analogous to the acute reactions suffered by torture and trauma victims, including posttraumatic stress disorder and the kind of psychiatric consequences that plague victims of what are called ‘deprivation and constraint’ torture techniques” (pp. 32-33).

The American Psychiatric Association, concerned about the conflicts inherent in such interrogation assistance, in 2006 explicitly condemned any direct involvement of their members in interrogations of specific detainees or prisoners, in domestic or national security settings. The Association stated in May 2006:

“No psychiatrist should participate directly in the interrogation of persons held in custody by military or civilian investigative or law enforcement authorities, whether in the United States or elsewhere. Direct participation includes being present in the interrogation room, asking or suggesting questions, or advising authorities on the use of specific techniques of interrogation with particular detainees.”

Until the membership forced a change in APA policy in September 2008, psychologists were allowed to aid interrogations as long as they did not participate in torture or “cruel, inhuman, or degrading treatment or punishment” and followed the APA’s ethics code. Psychologists like Michael Gelles are subject to the APA ethics code, if they are members of the Association, as is Dr. Gelles. In addition, the military requires psychologists consulting to interrogations to be licensed by a state as health providers and most states require adherence to the APA ethics code as a requirement of licensure.

According to the APA, the prolonged use of isolation to aid interrogations, as was clearly the case with al-Qahtani, constitutes “cruel, inhuman, or degrading treatment.” In August 2007, the APA, under member pressure, banned psychologist participation in a number of interrogation techniques as constituting either “torture” or “cruel, inhuman or degrading treatment or punishment,” including

“the following used for the purposes of eliciting information in an interrogation process… isolation… used in a manner that represents significant pain or suffering or in a manner that a reasonable person would judge to cause lasting harm.”

After this resolution was passed, it came under withering criticism from dissident psychologists and the press. As a consequence, the APA’s Ethics Director was forced to issue a clarifying statement in response to reports of four weeks mandatory isolation for new detainees at Guantanamo:

“[T]he 2007 Resolution should never be interpreted as allowing isolation, sensory deprivation and over-stimulation, or sleep deprivation either alone or in combination to be used as interrogation techniques to break down a detainee in order to elicit information.”

In February 2008, in response to criticism, the APA amended its 2007 Resolution to unambiguously condemn psychologist involvement in the use of isolation. The revised resolution proclaimed:

“An absolute prohibition against the following techniques…: … isolation…. Psychologists are absolutely prohibited from knowingly planning, designing, participating in or assisting in the use of all condemned techniques at any time and may not enlist others to employ these techniques in order to circumvent this resolution’s prohibition.”

The CITF/FBI interrogation plan for al-Qahtani indicates that Gelles clearly engaged in a prohibited activity: “knowingly planning, designing… the use of … condemned techniques… and may not enlist others to employ these techniques….” Interestingly, when I raised concerns about the loophole regarding isolation in the 2007 Resolution at the APA convention the day after its passage, Gelles said to me “Steve, you have to understand that isolation is often used only very temporarily, only for a few hours” [quote from memory]. He did not mention its use for months at Guantanamo nor his team’s recommendation that it be used for up to a year on al-Qahtani.

Another ethical concern arises from the reported psychological distress that al-Qahtani was experiencing prior to the CITF/FBI interrogation plan being developed. The interrogation plan notes al-Qahtani’s psychotic symptoms, but, other than suggesting a mental evaluation, they simply view his vulnerability as an opportunity for exploitation. This ignoring of al-Qahtani’s mental distress violates the fundamental Principle A undergirding the entire APA ethics code:

“Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons…. When conflicts occur among psychologists’ obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm.”

There is simply no evidence that Gelles and the other authors of this plan sought to “avoid or minimize harm.” Rather, as the plan makes clear, their intention was to systematically increase and exploit distress and disorientation experienced by al-Qahtani, in violation of the ethics code.

The entire plan, with its emphasis on “exploit[ing]” al-Qahtani’s need for human contact violates the ethic’s code’s ban on exploitation:

“Psychologists do not exploit persons over whom they have supervisory, evaluative, or other authority such as clients/patients, students, supervisees, research participants, and employees.” [Ethics Standard 3.08]

Clearly Gelles and the other mental health professionals had, at a minimum, “evaluative authority” over al-Qahtani as they developed their plans to exploit his weaknesses.

Counterintelligence operative DeBatto also expressed concerns regarding the plan’s proposal to impose additional stressors on al-Qahtani in order to render him more dependent upon the interrogator. As expressed by DeBatto:

“Depriving him of sheets, a mirror and adding other `stressors’ is utter nonsense and counterproductive. He has already endured months of stressors. Forcing him to endure more as a form of a ’stick and carrot’ approach will produce nothing of value. It also violates the interrogators’ ethical training and is blatantly in violation of U.S. and international law.”

Gelles’ proposals in the al-Qahtani case must be deemed unethical and, if executed, would have constituted gross violations of the APA Ethics code, as the APA itself asserted in detailing unethical conduct in detainee treatment in its resolutions of 2007 and 2008. The APA’s parading Gelles as a “heroic” upholder of ethical standards for military interrogations must be revisited. Gelles now joins the ranks of other APA psychologists, including Morgan Banks, Larry James, and Bryce Lefever, whom the organization upheld as models for ethical military interrogation processes, but who subsequently appeared sympathetic to or may have aided abusive practices.

As psychologist Jeffrey Kaye pointed out last summer in two articles [see my commentary here] ethical concerns about Gelles’ pre-Guantanamo interrogation actions had already been raised with the APA long prior to APA’s lauding him as the standard-bearer for psychological ethics in interrogations. Attorney Jonathan Turley reported filing an APA ethics complaint against Gelles for abuses in the prolonged isolation and interrogation of Navy Chief Petty Officer Daniel King, following an ambiguous polygraph result. As described by Turley in testimony before the Senate Intelligence Committee, King requested a mental health consultation because he felt he was losing his grip on reality. Dr. Gelles met with King for a consultation and, according to Turley, ignored King’s reports of suicidal thoughts. Instead, Gelles made help for King contingent upon King’s confession to espionage charges he had denied. Turley, who represented King, reports that the APA did not respond to his ethics complaint against Gelles. To our knowledge, the APA has never commented publicly on Turley’s charges, or on the ethics of Gelles’ treatment of King.

In any case, it turns out that Gelles was well aware of the potential ethical conflicts involved in his work with the CITF. In a 2003 paper in the Journal of Threat Assessment, apparently written at about the same time, Gelles and colleague Patrick Ewing argued that psychiatrists and psychologists involved in national security work should not be subject to professional ethics codes:

“Given the grave dangers faced by the United States and its allies post September 11, the government can ill afford to lose the input of psychologists, psychiatrists and other mental health professionals in cases involving national safety and security. Such input has been and will continue to be vital to protecting the lives of many Americans, civilian and military, at home and abroad. In order to maintain the ability and willingness of these dedicated professionals to continue in these roles, we cannot continue to place them in situations where the ethics of their conduct will be judged, post hoc, either by rules that have little if any relevance to their vital governmental functions or by professional organizations or licensing authorities based upon the weight the members of these bodies chose to afford competing interests…” (p. 106).

In 2005, two years after this article appeared, Gelles, along with James, Banks, and Lefever, was appointed by the APA, to the seminal APA Presidential Task Force on Psychological Ethics and National Security (PENS). This military- and intelligence-dominated group gave the ethical go-ahead for psychologists to aid detainee interrogations at Guantanamo and elsewhere.

In an open letter in 2007, psychologist Uwe Jacobs posed a series of questions to Dr. Gelles including:

“[W]hat were the techniques used that you did not find objectionable? To cite a few examples, did you believe it was ethical to transport prisoners to Guantanamo under conditions of sensory deprivation, i.e. wearing hoods, goggles, earmuffs, and other devices designed to create sensory deprivation and isolation, along with very restrictive shackling? Did you believe it was ethical to keep prisoners in solitary confinement for very long periods of time? Is it ethical to deprive prisoners of sleep? Is it ethical to subject them to severe heat and cold, constant noises or lights, stress positions, short shackling, screaming abuse etc.? You know the list I am referring to. Do you agree that these techniques have long been proven to produce severe nervous system dysregulation and often lasting psychological damage? Do these techniques not by definition constitute torture, just as stated by the UN?”

Gelles refused to answer Jacobs’ questions. We can surmise, from his earlier statements, that Gelles simply did not believe that intelligence psychologists should “be judged, post hoc, either by [ethical] rules that have little if any relevance to their vital governmental functions….” The APA has yet to explain why it appointed to the PENS task force someone who had already expressed disdain for the APA ethics code and why it continues to extol Gelles as a paragon of psychological ethics in interrogations.

Note: I would like to thank Jeffrey Kaye for pointing me to the Ewing and Gelles paper.

December 7th, 2009

Psychiatrist warning of violence danger among returned Marines fired

UPDATED AND EXPANDED: In the wake of the Fort Hood tragedy, there have been media reports that mental health staff had been concerned about Major Hasan, but did not report their concerns to higher authorities. Rather, these staff hoped he would disappear, into Fort Hood and then Afghanistan.The press and pundits have been extremely critical of those professionals for failing on act on their concerns.

Meanwhile, Mark Benjamin today tells of a psychiatrist serving the military who did express his concerns about potential tragedy, and was “disappeared” by firing as a consequence. Benjamin tells the story of Dr. Kernan Manion, a civilian contract psychiatrist at Camp Lejeune in North Carolina who repeatedly warned that Marines recently returned from combat zones were in danger of acting violently, whether toward themselves or others.

“A significant number of Navy medical officials and Marine commanders do not get it,” a frustrated Manion said about the situation at Camp Lejeune. “They do not understand the implications of what happens if somebody loses it,” explained Manion, who has 25 years of experience as a psychiatrist and who also specializes in traumatic brain injury — exactly the kinds of skills needed so desperately at military hospitals, because mental problems and brain injuries are the signature wounds of the ongoing wars. “People either commit suicide, commit homicide, get drunk, beat up the wife, all these things. I’ve seen it,” he added. “That is how serious this is and they just don’t get it.”

Dr. Manion followed procedures and expressed his concerns to the chain of command:

In an April 24 memo to his superiors, including Cmdr. Robert O’Byrne, head of mental health for the Camp Lejeune Naval Hospital, Manion describes a frustrated Marine punching a telephone pole with his bare fists outside a treatment clinic, then storming around, cursing, with a piece of lumber with a nail in it, though nothing was done to ensure he didn’t hurt himself, again, or others. In another case, a severely homicidal and suicidal Marine pounded his fists into a table and stormed out of treatment. Yet the hospital, Manion complained to his superiors, made no efforts to discuss these cases or how to better handle similar events in the future.

Manion was instructed by his contractor employer to shut up:

On June 24, a supervisor for the contractor warned Manion to stop making trouble. “Kernan Manion, it is requested that you cease and desist all further correspondence with the government,” the supervisor with NiteLines, Pamela Friend, wrote to Manion.

When he got no response from his employer or the commanders at the base, he took the next step specified by regulations for complaints. He wrote to the various Inspectors General:

On Aug. 30, he appealed to a series of military inspectors general in a written complaint. He warned of an “immediate threat of loss of life and/or harm to service members’ selves or others” if conditions did not improve. He complained of a “complete disregard for … implications for patient safety and well-being.” He decried that officials at Lejeune had ignored “repeated overt and emphatically stated concerns about the very safety and overall welfare of the affected patients.” And he warned that “many patients’ lives are imminently at risk.”

As a result, four days later Manion was fired, effective immediately, with no reason given. His contractor employer told Benjamin that the firing was at the request of the Navy.

While it may be tempting to see a giant conspiracy at work here, I believe the processes involved are more subtle. There are indications that the top military brass and Pentagon officials are genuinely concerned about the rampant trauma, including PTSD among troops returning from combat zones. They have funded studies, instituted screening programs, and increased treatment resources, both on the battlefield and after deployment.

There is, however, little evidence that this concern has filtered down to middle-level officers and officials. The problem is at least partly psychological. Much of the military is still in a “see no evil, hear no evil” mode of massive denial, in which they assume that highly traumatized troops are malingerers. The macho culture of the military, especially the Marines, is threatened by real acceptance that exposure to combat can profoundly damage many otherwise healthy individuals. It is easier to assume that those negatively affected must have had something wrong with them to begin with.  The brass and Pentagon officials would need to take much stronger steps to get officers, NCOs, and officials up and down the chain of command to openly face this serious problem.

Further, to really accept the extent of combat-associated trauma among our troops is to face some of the consequences of our wars without end. The pursuit of these wars depends upon the ability to deny, to oneself and to the public, the immensity of their negative consequences. US officials denied the extent of civilian casualties in Iraq and they deny the extent of trauma their policies are creating among US troops.

Often the denial isn’t total. It is briefly acknowledged and then turned away from with a claim to oneself and to others that the problem is being dealt with. But efforts to improve the mental health of troops while laudable, remain woefully inadequate. The single action that would most improve the situation, to end the repeated deployments to combat settings where the dangers are many and the goals elusive, remains off the table.

In the meantime, Dr. Manion remains concerned about the marines he is no longer allowed to treat:

He still worries. “I don’t like seeing these guys mistreated,” Manion said. “This is akin to somebody dying on the battlefield and not being attended to,” he added. “These guys are saying they are broken and need help, and the system is saying, ‘next, next, next.’”

Mark Benjamin’s article:

Camp Lejeune whistle-blower fired
A psychiatrist who tried to prevent Fort Hood-style violence among Marines about to “lose it” instead loses his job

By Mark Benjamin

Last April, two Marines at Camp Lejeune predicted to a psychiatrist that some Marine back from war was going to “lose it.” Concerned, the psychiatrist asked what that meant. One of the Marines responded, “One of these guys is liable to come back with a loaded weapon and open fire.”

They weren’t talking about Marines suffering from a tangle of mental and religious angst, like news reports suggest haunted the alleged Fort Hood shooter, Maj. Nidal Malik Hasan. The risk they reported at Camp Lejeune was broader and systemic. Upon returning home, troops suffering mental health problems were getting dumped into an overwhelmed healthcare system that responded ineptly to their crises, the men reported, and they also faced harassment from Marine Corps superiors ignorant of the severity of their problems and disdainful of those who sought psychiatric help.

As Dr. Kernan Manion investigated the two Marines’ claims about conditions at the North Carolina military base, the largest Marine base on the East Coast, he found they were true. Manion, a psychiatrist hired last January to treat Marines coming home from war with acute mental problems, warned his superiors of looming trouble at Camp Lejeune in a series of increasingly urgent memos.

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But instead of being praised for preventing what might have been another Fort Hood massacre, Manion was fired by the contractor that hired him, NiteLines Kuhana LLC. A spokeswoman for the firm says it let Manion go at the Navy’s behest. The Navy declined to comment on this story.

While military officials and the media examine whether the Army missed warning signs that might have indicated an unhinged Nidal Hasan was capable of killing 13 people at Fort Hood, Manion’s Camp Lejeune story is a cautionary tale of what happens to those who blow the whistle on conditions for military personnel with mental problems.

Manion says the April incident with the two Marines was just one of a series of disturbing events and serious problems with mental healthcare he saw at Camp Lejeune, a base that may be best known for a water contamination scandal that led to high rates of cancer and birth defects among Marines and their families who lived there. He was particularly concerned to see that troubled Marines were stricken with the overwhelming impulse to commit suicide or murder, telltale signs of severe combat stress.

In a telephone interview from his Surf City, N.C., home, Manion talked of overburdened staff and inadequate resources at the Naval hospital at Camp Lejeune. The psychiatrist charged that medical officials failed to study and discuss violent events among returning Marines in an effort to prevent further, similar events, and did little planning to improve handling distraught Marines who were killing themselves and others in shocking numbers. In 2008, for example, 42 Marines committed suicide and 146 attempted to do so, according to the Marine Corps.

Coincidentally or not, within 12 hours of Hasan’s shooting spree, Camp Lejeune officials discovered the body of one Marine and took into custody another Marine, Pvt. Jonathan Law, who is accused of killing his colleague. Law, who had served a seven-month tour in Iraq, was suffering from self-inflicted wounds when arrested.

Mirroring reports from military installations across the country, Manion also reported harassment of Marines seeking mental help. The psychiatrist began to worry about the possibility of a major outburst of violence on the base.

“A significant number of Navy medical officials and Marine commanders do not get it,” a frustrated Manion said about the situation at Camp Lejeune. “They do not understand the implications of what happens if somebody loses it,” explained Manion, who has 25 years of experience as a psychiatrist and who also specializes in traumatic brain injury — exactly the kinds of skills needed so desperately at military hospitals, because mental problems and brain injuries are the signature wounds of the ongoing wars. “People either commit suicide, commit homicide, get drunk, beat up the wife, all these things. I’ve seen it,” he added. “That is how serious this is and they just don’t get it.”

Manion believes he likely prevented a “Columbine-style attack” late last April after the two Marines who warned that someone might “lose it” directed him to a third Marine who seemed on the verge of violence. Manion also provided his superiors with documentation showing troubling incidents and neglect for the needs of returning Marines that could easily precipitate violence. Maybe not on the scale of the massacre at Fort Hood, but more like the rampage by a frustrated Sgt. John Russell, who gunned down five fellow soldiers at a military mental health facility in Baghdad last May.

Manion provided to Salon a stack of correspondence with superiors, a virtual crystal ball predicting dire consequences if mental healthcare at Camp Lejeune isn’t immediately improved.

In an April 24 memo to his superiors, including Cmdr. Robert O’Byrne, head of mental health for the Camp Lejeune Naval Hospital, Manion describes a frustrated Marine punching a telephone pole with his bare fists outside a treatment clinic, then storming around, cursing, with a piece of lumber with a nail in it, though nothing was done to ensure he didn’t hurt himself, again, or others. In another case, a severely homicidal and suicidal Marine pounded his fists into a table and stormed out of treatment. Yet the hospital, Manion complained to his superiors, made no efforts to discuss these cases or how to better handle similar events in the future.

“There was — and continues to be — no means of discussion of high-intensity/dangerous cases such as this,” a desperate Manion wrote on April 24. He warned of “immediate concerns of physical safety” at the base’s mental health facilities. Manion wanted to set up special protocols for handling intense situations, such as having specially trained MPs ready to intercede if things got bad, and a plan to hospitalize potentially violent patients quickly. “They dragged their feet on that,” he told me.

Within days that April, Manion intervened with the two Marines who’d warned of colleagues potentially losing it. They directed him to a third Marine who they believed was going to go on a shooting rampage. Manion worked hard to get that Marine into treatment, possibly averting bloodshed. The two Marines involved also reported harassment for working limited duty while seeking mental healthcare for themselves. They heatedly claimed that two noncommissioned officers had recently told them, “I don’t care why you are on [limited duty]. You are nothing but worthless pieces of shit,” according to an April 29 e-mail Manion sent to O’Byrne and others, complaining about such attitudes.

Like many healthcare providers at military bases across the country, Manion technically worked for a military contractor, Spectrum Healthcare Resources, a subcontractor for  NiteLines Kuhana LLC.

On June 24, a supervisor for the contractor warned Manion to stop making trouble. “Kernan Manion, it is requested that you cease and desist all further correspondence with the government,” the supervisor with NiteLines, Pamela Friend, wrote to Manion.

But Manion was still frustrated that Camp Lejeune did not seem to be taking these risks seriously. On Aug. 30, he appealed to a series of military inspectors general in a written complaint. He warned of an “immediate threat of loss of life and/or harm to service members’ selves or others” if conditions did not improve. He complained of a “complete disregard for … implications for patient safety and well-being.” He decried that officials at Lejeune had ignored “repeated overt and emphatically stated concerns about the very safety and overall welfare of the affected patients.” And he warned that “many patients’ lives are imminently at risk.”

Four days later, the contractor fired Manion “effective immediately,” according to his termination e-mail. The note provides no reason for the firing. Manion was directed to clean out his office the next day, under the watchful eye of a chief petty officer, and have no further contact with his patients.

In a statement to Salon, NiteLines said the Navy wanted Manion fired, but did not explain why. “The treatment facility at Camp Lejeune notified (Nitelines) that Dr. Manion did not meet the Government’s requirements in accordance with the contract, and they directed he be removed from the schedule,” it reads.

Salon e-mailed the spokesman for the Naval Hospital Camp Lejeune, Raymond Applewhite, with details of this story and then described some of these facts with him in a follow-up telephone call, requesting an interview with O’Byrne. The Navy did not respond further.

Manion left Camp Lejeune after he got fired, but he did not stop worrying about the potential for violence there. In mid-September, Manion filed a 14-page complaint with the Department of Defense inspector general. On Sept. 29, he warned the Navy’s Bureau of Medicine and Surgery inspector general in writing of “serious mismanagement of post-deployment mental health services that was both endangering patient, staff and community safety as well as severely compromising the quality of care” for returning Marines. Manion noted that the poor care at Camp Lejeune continued despite “the ever present threat of life-threatening violence by distraught service members towards themselves or others.”

Finally, Manion wrote President Obama that same day. “Frankly, in my more than 25 years of clinical practice, I’ve never seen such immense emotional suffering and psychological brokenness — literally a relentless stream of courageous, well-trained and formerly strong Marines deeply wounded psychologically by the immensity of their combat experience,” he wrote to the president. Manion added, however, that at Camp Lejeune, that immense problem was being met with “inadequate treatment” and “callous indifference.”

He still worries. “I don’t like seeing these guys mistreated,” Manion said. “This is akin to somebody dying on the battlefield and not being attended to,” he added. “These guys are saying they are broken and need help, and the system is saying, ‘next, next, next.’”

November 16th, 2009

The stresses of military mental health personnnel

As we ponder the tragedy at Fort hood, the New York Times has a good article on the stresses facing military psychiatrists and other military mental health personnel.

Painful Stories Take a Toll on Military Therapists

By Benedict Carey, Damien Cave, and Lizette Alvarez

Many of the patients who fill the day are bereft, angry, broken. Their experiences are gruesome, their distress lasting and the process of recovery exhausting. The repeated stories of battle and loss can leave the most professional therapist numb or angry.

And hanging over it all, for psychiatrists and psychologists in today’s military, is the prospect of their own deployment — of working under fire in Iraq or Afghanistan, where the Pentagon has assigned more therapists to combat units than in previous wars.

That was the world that Maj. Nidal Malik Hasan, an Army psychiatrist, inhabited until Thursday, when he was accused of one of the worst mass shootings ever on a military base in the United States, an attack that killed 13 and left dozens wounded. Five of the dead were fellow therapists, the Army said.

Major Hasan’s motives are still being investigated. But those who work day in and day out treating the psychological wounds of the country’s warriors say Thursday’s rampage has put a spotlight on the strains of their profession and of the patients they treat.

Major Hasan was one of a thin line of military therapists trying to hold off a rising tide of need. So far this year, 117 soldiers on active duty were reported to have committed suicide. The Army has only 408 psychiatrists — military, civilian and contractors — serving about 553,000 active-duty troops around the world. As a result, some soldiers home from war, suffering from nightmares and panic attacks, say they have waited almost a year to see a psychiatrist.

Many military professionals, meanwhile, describe crushing schedules with 10 or more patients a day, most struggling with devastating trauma or mutilated bodies that are the product of war and the highly advanced care that kept them alive.

Some of those hired to heal others end up needing help themselves. Some go home at night too depressed to talk to their children. Others, like Bret A. Moore, a former Army psychologist at Fort Hood, ultimately quit.

“I planned for a career in the military, but I burned out” after about five years, he said.

The biggest problem, Dr. Moore said, was “compassion fatigue.”

“I thought that was a bogus phenomenon, but it’s true,” he said. “You become detached, you start to feel like you can’t connect with your patients, you run out of empathy. And the last thing you want to do is talk about it with someone else. It really puts a wedge between you and loved ones.”

Whatever the facts in Major Hasan’s case, some therapists who work with the military agree that the tragedy is likely to have a “lasting impact on how we look at mental health providers,” said Dr. Martin Paulus, a psychiatrist at the University of California, San Diego, and the Veterans Affairs San Diego Healthcare System.

The Army has added to their ranks in recent years, as the number of soldiers with the diagnosis of post-traumatic stress disorder has climbed to 34,000. But the shooting has raised a pressing question: Who counsels the counselors? Dr. Moore and other therapists who have worked in the military or for Veterans Affairs said that mental health evaluations of therapists themselves were virtually nonexistent.

“I have worked with the Army, the Navy, the V.A., and I’m not aware of any formal, systematic process to evaluate professionals,” said Dr. Andy Morgan, a psychiatrist at the National Center for P.T.S.D.

At Walter Reed, where Major Hasan was in training until recently, Lt. Col. Brett Schneider, a psychiatrist, described a complicated system of checks and balances, including a training committee with superiors and civilians who evaluate residents and mental health staff members.

“There is a lot more built into the processes to keep tabs on each other,” said Colonel Schneider, who spoke on the condition that he not be asked any questions about Major Hasan. “If somebody is starting to get to the point where these things are a problem, there are a number of ways we can intervene.”

Generally, though, the military, like many large civilian employers, relies on self-evaluation and voluntary employee-assistance programs.

“Once training is over, you’re basically on your own,” Dr. Paulus said.

At Fort Hood, the nation’s largest military base, Major Hasan, like other therapists, would have had to manage many patients with severe combat stress. At his relatively high rank, he would have been expected to seek help on his own if he thought he needed it, experts said.

The base sees continual traffic in and out of war zones, and the work conditions are especially stressful, according to at least one report provided to the Army.

Dr. Stephen M. Stahl, a psychiatrist at the University of California, San Diego, who worked on the report, said the base’s program for soldiers returning from war simply lacked the staff it needed. He said there were about 15 psychiatrists on staff, treating hundreds of inpatients and outpatients. Generally, the psychiatrists did not do therapy but prescribed medication.

“They’re so under-resourced that people just don’t end up getting enough care,” Dr. Stahl said.

He added: “It’s a pretty damn stressful place to be. I think it’s a horrible place to practice psychiatry.”

Soldiers described similar situations at many other installations. Jason Yorty, 34, an Arabic linguist with the Army who deployed to Iraq four times and Afghanistan once, said that when he returned to Fort Gordon in Georgia two years ago, the system appeared to be overwhelmed and resistant to diagnosing problems that would require multiple visits.

First, he said, he saw a physician’s assistant at the base, then a clinical social worker, neither of whom agreed that his nightmares and panic attacks amounted to post-traumatic stress disorder. “It took me eight months just to get an appointment to see a psychiatrist,” he said. “When I got there, he blew me off.”

A few weeks later, after he refused the Army psychiatrist’s prescription for a sleep aid, a nonmilitary mental health provider gave him a diagnosis of P.T.S.D.

Experts say that the military has made big strides in taking mental health issues seriously, but that military therapists are sometimes pressured to place the needs of the force above the needs of the patient. Indeed, they can be overruled by commanders who need soldiers in the field.

Since 2001, the military has deployed many soldiers with post-traumatic stress disorder or other ailments. “The focus in the military is readiness,” said Charles Figley, a psychologist at Tulane University. “There is an inherent conflict.”

And in war zones, the relationships between soldiers and mental health providers can be especially fraught. Therapists in Iraq said that they could often do little more than provide a few coping tips to soldiers, just enough to keep them functioning. There were simply too many people and not enough time, as Army officials have acknowledged.

Providing care has its own risks. In studies of therapists working to soothe mental distress in victims of violence, whether criminal, sexual or combat-related, researchers have documented what is called secondary trauma: contact distress, of a kind. In one 2004 study of social workers on cases stemming from the Sept. 11 attacks, researchers found that the more deeply therapists were involved with victims, the more likely they were to experience such trauma. The same associations have been found in doctors working with survivors in war zones.

Dr. Hasan was reportedly facing his first deployment — a prospect that scares even trained fighters, many of whom become increasingly frantic before going to war, according to surveys.

The workload itself is enough to give psychiatrists and psychologists pause. In Iraq, with sectarian violence at its peak in 2007, officials say there were 200 such specialists serving more than 130,000 troops, driving between bases on bomb-rigged roads.

The experience of Lt. Col. Reagon P. Carr was common. In six months with the Second Brigade of the 10th Mountain Division in 2007, he said he saw more than 700 soldiers. In one typical week, he visited three locations, meeting with 36 soldiers who came in for immediate help: 3 were contemplating suicide, a dozen were unable to sleep, 5 said they were apprehensive about returning to a dysfunctional marriage and 16 said they were disgruntled with their leadership.

Few who are deployed feel prepared for this punishing task.

Dr. Peter Linnerooth, a former Army psychologist who treated soldiers in Germany and Iraq and at Fort Hood, said that in Schweinfurt, Germany, he was the sole psychologist for a community of 10,000 people in 2005.

At Fort Hood, he treated a burly man whose job in Iraq was to recover the bodies of soldiers. His patient was devastated by one particular loss, Dr. Linnerooth said.

“He had picked up this corpse that was so badly burned, it weighed about 20 pounds,” he said. “He was this big, tough, awesome guy. For him, it was like picking up his daughter. That was an extreme case. But you get those at least once or twice a week.”

If it turns out that Major Hasan did in fact break partly under the stress of the job and impending deployment, many veterans would not be surprised.

“If this guy can go over the edge, imagine what it is like for the actual combat troops who have been through four or five deployments,” said Bryan Hannah, 22, a disabled Iraq war veteran from San Marcos, Tex., who was stationed at Fort Hood until he was discharged a year ago because of post-traumatic stress disorder and other injuries.

He added, “There are a lot of others who are worse off than him.”

Erica Goode and Gretel C. Kovach contributed reporting.

November 8th, 2009

New study: Green space improves physical and mental health

A new study finds that the presence of green space in one’s neighborhood leads to improved physical and mental health. Here is a BBC account:

There is more evidence that living near a ‘green space’ has health benefits.

Research in the Journal of Epidemiology and Community Health says the impact is particularly noticeable in reducing rates of mental ill health.

The annual rates of 15 out of 24 major physical diseases were also significantly lower among those living closer to green spaces.

One environmental expert said the study confirmed that green spaces create ‘oases’ of improved health around them.

The researchers from the VU University Medical Centre in Amsterdam looked at the health records of 350,000 people registered with 195 family doctors across the Netherlands.

Only people who had been registered with their GP for longer than 12 months were included because the study assumed this was the minimum amount of time people would have to live in an environment before any effect of it would be noticeable.

Health impact

The percentages of green space within a one and three kilometre (0.62 and 1.86 miles) radius of their home were calculated using their postcode.

On average, green space accounted for 42% of the residential area within one kilometre (0.62 miles) radius and almost 61% within a three kilometre (1.86 miles) radius of people’s homes.

And the annual rates for 24 diseases in 7 different categories were calculated.

The health benefits for most of the diseases were only seen when the greenery was within a one kilometre ( 0.62 miles ) radius of the home.

The exceptions to this were anxiety disorders, infectious diseases of the digestive system and medically unexplained physical symptoms which were seen to benefit even when the green spaces were within three kilometres of the home.

The biggest impact was on anxiety disorders and depression.

Anxiety disorders

The annual prevalence of anxiety disorders for those living in a residential area containing 10% of green space within a one kilometre (0.62 miles) radius of their home was 26 per 1000 whereas for those living in an area containing 90% of green space it was 18 per 1000.

For depression the rates were 32 per 1000 for the people in the more built up areas and 24 per 1000 for those in the greener areas.

The researchers also showed that this relation was strongest for children younger than 12.

They were 21% less likely to suffer from depression in the greener areas.

Two unexpected findings were that the greener spaces did not show benefits for high blood pressure and that the relation appeared stronger for people aged 46 to 65 than for the elderly.

The researchers think the green spaces help recovery from stress and offer greater opportunities for social contacts.

They say the free physical exercise and better air quality could also contribute.

Dr Jolanda Maas of the VU University Medical Centre in Amsterdam, said: “It clearly shows that green spaces are not just a luxury but they relate directly to diseases and the way people feel in their living environments.”

“Most of the diseases which are related to green spaces are diseases which are highly prevalent and costly to treat so policy makers need to realise that this is something they may be able to diminish with green spaces.”

Professor Barbara Maher of the Lancaster Environment Centre said the study confirmed that green spaces create oases of improved health around them especially for children.

She said: “At least part of this ‘oasis’ effect probably reflects changes in air quality.

“Anything that reduces our exposure to the modern-day ‘cocktail’ of atmospheric pollutants has got to be a good thing.”

Here is the study abstract:

Background: Due to increasing urbanisation people face the prospect of living in environments with few green spaces. There is increasing evidence for a positive relation between green space in people’s living environment and self-reported indicators of physical and mental health. This study investigates whether physician assessed morbidity is also related to green space in people’s living environment.

Methods: Morbidity data were derived from electronic medical records of 195 general practitioners in 96 Dutch practices, serving a population of 345,143 people. Morbidity was classified by the general practitioners according to the International Classification of Primary Care (ICPC). The percentage of green space within a one kilometre and three kilometre radius around the postal code coordinates was derived from an existing database and was calculated for each household. Multilevel logistic regression analyses were performed controlling for demographic and socio-economic characteristics.

Results: The annual prevalence rate of 15 of the 24 disease clusters was lower in living environments with more green space in a 1 km radius. The relation was strongest for anxiety disorder and depression. The relation was stronger for children and people with a lower socio-economic status. Furthermore, the relation was strongest in slightly urban areas and not apparent in very strongly urban areas.

Conclusion: This study indicates that the previously established relation between green space and a number of self-reported general indicators of physical and mental health can also be found for clusters of specific physician assessed morbidity. The study stresses the importance of green space close to home for children and lower socio-economic groups.

October 15th, 2009

Placebo effect getting stronger. Drug companies worry.

Wired has a fascinating article on a major problem bedeviling the pharmaceutical companies. Their drugs are faring less well than they used to against placebo. It is sad how little of the article is devoted to ways to therapeutically harness the placebo effect. These applications, alas, are not likely to make money for the drug companies:

Placebos Are Getting More Effective. Drugmakers Are Desperate to Know Why

By Steve Silberman

Merck was in trouble. In 2002, the pharmaceutical giant was falling behind its rivals in sales. Even worse, patents on five blockbuster drugs were about to expire, which would allow cheaper generics to flood the market. The company hadn’t introduced a truly new product in three years, and its stock price was plummeting.

In interviews with the press, Edward Scolnick, Merck’s research director, laid out his battle plan to restore the firm to preeminence. Key to his strategy was expanding the company’s reach into the antidepressant market, where Merck had lagged while competitors like Pfizer and GlaxoSmithKline created some of the best-selling drugs in the world. “To remain dominant in the future,” he told Forbes, “we need to dominate the central nervous system.”

His plan hinged on the success of an experimental antidepressant codenamed MK-869. Still in clinical trials, it looked like every pharma executive’s dream: a new kind of medication that exploited brain chemistry in innovative ways to promote feelings of well-being. The drug tested brilliantly early on, with minimal side effects, and Merck touted its game-changing potential at a meeting of 300 securities analysts.

Behind the scenes, however, MK-869 was starting to unravel. True, many test subjects treated with the medication felt their hopelessness and anxiety lift. But so did nearly the same number who took a placebo, a look-alike pill made of milk sugar or another inert substance given to groups of volunteers in clinical trials to gauge how much more effective the real drug is by comparison. The fact that taking a faux drug can powerfully improve some people’s health—the so-called placebo effect—has long been considered an embarrassment to the serious practice of pharmacology.

Ultimately, Merck’s foray into the antidepressant market failed. In subsequent tests, MK-869 turned out to be no more effective than a placebo. In the jargon of the industry, the trials crossed the futility boundary.

MK-869 wasn’t the only highly anticipated medical breakthrough to be undone in recent years by the placebo effect. From 2001 to 2006, the percentage of new products cut from development after Phase II clinical trials, when drugs are first tested against placebo, rose by 20 percent. The failure rate in more extensive Phase III trials increased by 11 percent, mainly due to surprisingly poor showings against placebo. Despite historic levels of industry investment in R&D, the US Food and Drug Administration approved only 19 first-of-their-kind remedies in 2007—the fewest since 1983—and just 24 in 2008. Half of all drugs that fail in late-stage trials drop out of the pipeline due to their inability to beat sugar pills.

The upshot is fewer new medicines available to ailing patients and more financial woes for the beleaguered pharmaceutical industry. Last November, a new type of gene therapy for Parkinson’s disease, championed by the Michael J. Fox Foundation, was abruptly withdrawn from Phase II trials after unexpectedly tanking against placebo. A stem-cell startup called Osiris Therapeutics got a drubbing on Wall Street in March, when it suspended trials of its pill for Crohn’s disease, an intestinal ailment, citing an “unusually high” response to placebo. Two days later, Eli Lilly broke off testing of a much-touted new drug for schizophrenia when volunteers showed double the expected level of placebo response.

It’s not only trials of new drugs that are crossing the futility boundary. Some products that have been on the market for decades, like Prozac, are faltering in more recent follow-up tests. In many cases, these are the compounds that, in the late ’90s, made Big Pharma more profitable than Big Oil. But if these same drugs were vetted now, the FDA might not approve some of them. Two comprehensive analyses of antidepressant trials have uncovered a dramatic increase in placebo response since the 1980s. One estimated that the so-called effect size (a measure of statistical significance) in placebo groups had nearly doubled over that time.

It’s not that the old meds are getting weaker, drug developers say. It’s as if the placebo effect is somehow getting stronger.

The fact that an increasing number of medications are unable to beat sugar pills has thrown the industry into crisis. The stakes could hardly be higher. In today’s economy, the fate of a long-established company can hang on the outcome of a handful of tests.

Why are inert pills suddenly overwhelming promising new drugs and established medicines alike? The reasons are only just beginning to be understood. A network of independent researchers is doggedly uncovering the inner workings—and potential therapeutic applications—of the placebo effect. At the same time, drugmakers are realizing they need to fully understand the mechanisms behind it so they can design trials that differentiate more clearly between the beneficial effects of their products and the body’s innate ability to heal itself. A special task force of the Foundation for the National Institutes of Health is seeking to stem the crisis by quietly undertaking one of the most ambitious data-sharing efforts in the history of the drug industry. After decades in the jungles of fringe science, the placebo effect has become the elephant in the boardroom.

The roots of the placebo problem can be traced to a lie told by an Army nurse during World War II as Allied forces stormed the beaches of southern Italy. The nurse was assisting an anesthetist named Henry Beecher, who was tending to US troops under heavy German bombardment. When the morphine supply ran low, the nurse assured a wounded soldier that he was getting a shot of potent painkiller, though her syringe contained only salt water. Amazingly, the bogus injection relieved the soldier’s agony and prevented the onset of shock.

Returning to his post at Harvard after the war, Beecher became one of the nation’s leading medical reformers. Inspired by the nurse’s healing act of deception, he launched a crusade to promote a method of testing new medicines to find out whether they were truly effective. At the time, the process for vetting drugs was sloppy at best: Pharmaceutical companies would simply dose volunteers with an experimental agent until the side effects swamped the presumed benefits. Beecher proposed that if test subjects could be compared to a group that received a placebo, health officials would finally have an impartial way to determine whether a medicine was actually responsible for making a patient better.

In a 1955 paper titled “The Powerful Placebo,” published in The Journal of the American Medical Association, Beecher described how the placebo effect had undermined the results of more than a dozen trials by causing improvement that was mistakenly attributed to the drugs being tested. He demonstrated that trial volunteers who got real medication were also subject to placebo effects; the act of taking a pill was itself somehow therapeutic, boosting the curative power of the medicine. Only by subtracting the improvement in a placebo control group could the actual value of the drug be calculated.

The article caused a sensation. By 1962, reeling from news of birth defects caused by a drug called thalidomide, Congress amended the Food, Drug, and Cosmetic Act, requiring trials to include enhanced safety testing and placebo control groups. Volunteers would be assigned randomly to receive either medicine or a sugar pill, and neither doctor nor patient would know the difference until the trial was over. Beecher’s double-blind, placebo-controlled, randomized clinical trial—or RCT—was enshrined as the gold standard of the emerging pharmaceutical industry. Today, to win FDA approval, a new medication must beat placebo in at least two authenticated trials.

Beecher’s prescription helped cure the medical establishment of outright quackery, but it had an insidious side effect. By casting placebo as the villain in RCTs, he ended up stigmatizing one of his most important discoveries. The fact that even dummy capsules can kick-start the body’s recovery engine became a problem for drug developers to overcome, rather than a phenomenon that could guide doctors toward a better understanding of the healing process and how to drive it most effectively.

In his eagerness to promote his template for clinical trials, Beecher also overreached by seeing the placebo effect at work in curing ailments like the common cold, which wane with no intervention at all. But the triumph of Beecher’s gold standard was a generation of safer medications that worked for nearly everyone. Anthracyclines don’t require an oncologist with a genial bedside manner to slow the growth of tumors.

What Beecher didn’t foresee, however, was the explosive growth of the pharmaceutical industry. The blockbuster success of mood drugs in the ’80s and ’90s emboldened Big Pharma to promote remedies for a growing panoply of disorders that are intimately related to higher brain function. By attempting to dominate the central nervous system, Big Pharma gambled its future on treating ailments that have turned out to be particularly susceptible to the placebo effect.

The tall, rusty-haired son of a country doctor, William Potter, 64, has spent most of his life treating mental illness—first as a psychiatrist at the National Institute of Mental Health and then as a drug developer. A decade ago, he took a job at Lilly’s neuroscience labs. There, working on new antidepressants and antianxiety meds, he became one of the first researchers to glimpse the approaching storm.

To test products internally, pharmaceutical companies routinely run trials in which a long-established medication and an experimental one compete against each other as well as against a placebo. As head of Lilly’s early-stage psychiatric drug development in the late ’90s, Potter saw that even durable warhorses like Prozac, which had been on the market for years, were being overtaken by dummy pills in more recent tests. The company’s next-generation antidepressants were faring badly, too, doing no better than placebo in seven out of 10 trials.

As a psychiatrist, Potter knew that some patients really do seem to get healthier for reasons that have more to do with a doctor’s empathy than with the contents of a pill. But it baffled him that drugs he’d been prescribing for years seemed to be struggling to prove their effectiveness. Thinking that something crucial may have been overlooked, Potter tapped an IT geek named David DeBrota to help him comb through the Lilly database of published and unpublished trials—including those that the company had kept secret because of high placebo response. They aggregated the findings from decades of antidepressant trials, looking for patterns and trying to see what was changing over time. What they found challenged some of the industry’s basic assumptions about its drug-vetting process.

Assumption number one was that if a trial were managed correctly, a medication would perform as well or badly in a Phoenix hospital as in a Bangalore clinic. Potter discovered, however, that geographic location alone could determine whether a drug bested placebo or crossed the futility boundary. By the late ’90s, for example, the classic antianxiety drug diazepam (also known as Valium) was still beating placebo in France and Belgium. But when the drug was tested in the US, it was likely to fail. Conversely, Prozac performed better in America than it did in western Europe and South Africa. It was an unsettling prospect: FDA approval could hinge on where the company chose to conduct a trial.

Mistaken assumption number two was that the standard tests used to gauge volunteers’ improvement in trials yielded consistent results. Potter and his colleagues discovered that ratings by trial observers varied significantly from one testing site to another. It was like finding out that the judges in a tight race each had a different idea about the placement of the finish line.

Potter and DeBrota’s data-mining also revealed that even superbly managed trials were subject to runaway placebo effects. But exactly why any of this was happening remained elusive. “We were able to identify many of the core issues in play,” Potter says. “But there was no clear answer to the problem.” Convinced that what Lilly was facing was too complex for any one pharmaceutical house to unravel on its own, he came up with a plan to break down the firewalls between researchers across the industry, enabling them to share data in “pre-competitive space.”

After prodding by Potter and others, the NIH focused on the issue in 2000, hosting a three-day conference in Washington. For the first time in medical history, more than 500 drug developers, doctors, academics, and trial designers put their heads together to examine the role of the placebo effect in clinical trials and healing in general.

Potter’s ambitious plan for a collaborative approach to the problem eventually ran into its own futility boundary: No one would pay for it. And drug companies don’t share data, they hoard it. But the NIH conference launched a new wave of placebo research in academic labs in the US and Italy that would make significant progress toward solving the mystery of what was happening in clinical trials.

Visitors to Fabrizio Benedetti’s clinic at the University of Turin are asked never to say the P-word around the med students who sign up for his experiments. For all the volunteers know, the trim, soft-spoken neuroscientist is hard at work concocting analgesic skin creams and methods for enhancing athletic performance.

One recent afternoon in his lab, a young soccer player grimaced with exertion while doing leg curls on a weight machine. Benedetti and his colleagues were exploring the potential of using Pavlovian conditioning to give athletes a competitive edge undetectable by anti-doping authorities. A player would receive doses of a performance-enhancing drug for weeks and then a jolt of placebo just before competition.

Benedetti, 53, first became interested in placebos in the mid-’90s, while researching pain. He was surprised that some of the test subjects in his placebo groups seemed to suffer less than those on active drugs. But scientific interest in this phenomenon, and the money to research it, were hard to come by. “The placebo effect was considered little more than a nuisance,” he recalls. “Drug companies, physicians, and clinicians were not interested in understanding its mechanisms. They were concerned only with figuring out whether their drugs worked better.”

Part of the problem was that response to placebo was considered a psychological trait related to neurosis and gullibility rather than a physiological phenomenon that could be scrutinized in the lab and manipulated for therapeutic benefit. But then Benedetti came across a study, done years earlier, that suggested the placebo effect had a neurological foundation. US scientists had found that a drug called naloxone blocks the pain-relieving power of placebo treatments. The brain produces its own analgesic compounds called opioids, released under conditions of stress, and naloxone blocks the action of these natural painkillers and their synthetic analogs. The study gave Benedetti the lead he needed to pursue his own research while running small clinical trials for drug companies.

Now, after 15 years of experimentation, he has succeeded in mapping many of the biochemical reactions responsible for the placebo effect, uncovering a broad repertoire of self-healing responses. Placebo-activated opioids, for example, not only relieve pain; they also modulate heart rate and respiration. The neurotransmitter dopamine, when released by placebo treatment, helps improve motor function in Parkinson’s patients. Mechanisms like these can elevate mood, sharpen cognitive ability, alleviate digestive disorders, relieve insomnia, and limit the secretion of stress-related hormones like insulin and cortisol.

In one study, Benedetti found that Alzheimer’s patients with impaired cognitive function get less pain relief from analgesic drugs than normal volunteers do. Using advanced methods of EEG analysis, he discovered that the connections between the patients’ prefrontal lobes and their opioid systems had been damaged. Healthy volunteers feel the benefit of medication plus a placebo boost. Patients who are unable to formulate ideas about the future because of cortical deficits, however, feel only the effect of the drug itself. The experiment suggests that because Alzheimer’s patients don’t get the benefits of anticipating the treatment, they require higher doses of painkillers to experience normal levels of relief.

Benedetti often uses the phrase “placebo response” instead of placebo effect. By definition, inert pills have no effect, but under the right conditions they can act as a catalyst for what he calls the body’s “endogenous health care system.” Like any other internal network, the placebo response has limits. It can ease the discomfort of chemotherapy, but it won’t stop the growth of tumors. It also works in reverse to produce the placebo’s evil twin, the nocebo effect. For example, men taking a commonly prescribed prostate drug who were informed that the medication may cause sexual dysfunction were twice as likely to become impotent.

Further research by Benedetti and others showed that the promise of treatment activates areas of the brain involved in weighing the significance of events and the seriousness of threats. “If a fire alarm goes off and you see smoke, you know something bad is going to happen and you get ready to escape,” explains Tor Wager, a neuroscientist at Columbia University. “Expectations about pain and pain relief work in a similar way. Placebo treatments tap into this system and orchestrate the responses in your brain and body accordingly.”

In other words, one way that placebo aids recovery is by hacking the mind’s ability to predict the future. We are constantly parsing the reactions of those around us—such as the tone a doctor uses to deliver a diagnosis—to generate more-accurate estimations of our fate. One of the most powerful placebogenic triggers is watching someone else experience the benefits of an alleged drug. Researchers call these social aspects of medicine the therapeutic ritual.

In a study last year, Harvard Medical School researcher Ted Kaptchuk devised a clever strategy for testing his volunteers’ response to varying levels of therapeutic ritual. The study focused on irritable bowel syndrome, a painful disorder that costs more than $40 billion a year worldwide to treat. First the volunteers were placed randomly in one of three groups. One group was simply put on a waiting list; researchers know that some patients get better just because they sign up for a trial. Another group received placebo treatment from a clinician who declined to engage in small talk. Volunteers in the third group got the same sham treatment from a clinician who asked them questions about symptoms, outlined the causes of IBS, and displayed optimism about their condition.

Not surprisingly, the health of those in the third group improved most. In fact, just by participating in the trial, volunteers in this high-interaction group got as much relief as did people taking the two leading prescription drugs for IBS. And the benefits of their bogus treatment persisted for weeks afterward, contrary to the belief—widespread in the pharmaceutical industry—that the placebo response is short-lived.

Studies like this open the door to hybrid treatment strategies that exploit the placebo effect to make real drugs safer and more effective. Cancer patients undergoing rounds of chemotherapy often suffer from debilitating nocebo effects—such as anticipatory nausea—conditioned by their past experiences with the drugs. A team of German researchers has shown that these associations can be unlearned through the administration of placebo, making chemo easier to bear.

Meanwhile, the classic use of placebos in medicine—to boost the confidence of anxious patients—has been employed tacitly for ages. Nearly half of the doctors polled in a 2007 survey in Chicago admitted to prescribing medications they knew were ineffective for a patient’s condition—or prescribing effective drugs in doses too low to produce actual benefit—in order to provoke a placebo response.

The main objections to more widespread placebo use in clinical practice are ethical, but the solutions to these conundrums can be surprisingly simple. Investigators told volunteers in one placebo study that the pills they were taking were “known to significantly reduce pain in some patients.” The researchers weren’t lying.

These new findings tell us that the body’s response to certain types of medication is in constant flux, affected by expectations of treatment, conditioning, beliefs, and social cues.

For instance, the geographic variations in trial outcome that Potter uncovered begin to make sense in light of discoveries that the placebo response is highly sensitive to cultural differences. Anthropologist Daniel Moerman found that Germans are high placebo reactors in trials of ulcer drugs but low in trials of drugs for hypertension—an undertreated condition in Germany, where many people pop pills for herzinsuffizienz, or low blood pressure. Moreover, a pill’s shape, size, branding, and price all influence its effects on the body. Soothing blue capsules make more effective tranquilizers than angry red ones, except among Italian men, for whom the color blue is associated with their national soccer team—Forza Azzurri!

But why would the placebo effect seem to be getting stronger worldwide? Part of the answer may be found in the drug industry’s own success in marketing its products.

Potential trial volunteers in the US have been deluged with ads for prescription medications since 1997, when the FDA amended its policy on direct-to-consumer advertising. The secret of running an effective campaign, Saatchi & Saatchi’s Jim Joseph told a trade journal last year, is associating a particular brand-name medication with other aspects of life that promote peace of mind: “Is it time with your children? Is it a good book curled up on the couch? Is it your favorite television show? Is it a little purple pill that helps you get rid of acid reflux?” By evoking such uplifting associations, researchers say, the ads set up the kind of expectations that induce a formidable placebo response.

The success of those ads in selling blockbuster drugs like antidepressants and statins also pushed trials offshore as therapeutic virgins—potential volunteers who were not already medicated with one or another drug—became harder to find. The contractors that manage trials for Big Pharma have moved aggressively into Africa, India, China, and the former Soviet Union. In these places, however, cultural dynamics can boost the placebo response in other ways. Doctors in these countries are paid to fill up trial rosters quickly, which may motivate them to recruit patients with milder forms of illness that yield more readily to placebo treatment. Furthermore, a patient’s hope of getting better and expectation of expert care—the primary placebo triggers in the brain—are particularly acute in societies where volunteers are clamoring to gain access to the most basic forms of medicine. “The quality of care that placebo patients get in trials is far superior to the best insurance you get in America,” says psychiatrist Arif Khan, principal investigator in hundreds of trials for companies like Pfizer and Bristol-Myers Squibb. “It’s basically luxury care.”

Big Pharma faces additional problems in beating placebo when it comes to psychiatric drugs. One is to accurately define the nature of mental illness. The litmus test of drug efficacy in antidepressant trials is a questionnaire called the Hamilton Depression Rating Scale. The HAM-D was created nearly 50 years ago based on a study of major depressive disorder in patients confined to asylums. Few trial volunteers now suffer from that level of illness. In fact, many experts are starting to wonder if what drug companies now call depression is even the same disease that the HAM-D was designed to diagnose.

Existing tests also may not be appropriate for diagnosing disorders like social anxiety and premenstrual dysphoria—the very types of chronic, fuzzily defined conditions that the drug industry started targeting in the ’90s, when the placebo problem began escalating. The neurological foundation of these illnesses is still being debated, making it even harder for drug companies to come up with effective treatments.

What all of these disorders have in common, however, is that they engage the higher cortical centers that generate beliefs and expectations, interpret social cues, and anticipate rewards. So do chronic pain, sexual dysfunction, Parkinson’s, and many other ailments that respond robustly to placebo treatment. To avoid investing in failure, researchers say, pharmaceutical companies will need to adopt new ways of vetting drugs that route around the brain’s own centralized network for healing.

Ten years and billions of R&D dollars after William Potter first sounded the alarm about the placebo effect, his message has finally gotten through. In the spring, Potter, who is now a VP at Merck, helped rev up a massive data-gathering effort called the Placebo Response Drug Trials Survey.

Under the auspices of the NIH, Potter and his colleagues are acquiring decades of trial data—including blood and DNA samples—to determine which variables are responsible for the apparent rise in the placebo effect. Merck, Lilly, Pfizer, AstraZeneca, GlaxoSmithKline, Sanofi-Aventis, Johnson & Johnson, and other major firms are funding the study, and the process of scrubbing volunteers’ names and other personal information from the database is about to begin.

In typically secretive industry fashion, the existence of the project itself is being kept under wraps. NIH staffers are willing to talk about it only anonymously, concerned about offending the companies paying for it.

For Potter, who used to ride along with his father on house calls in Indiana, the significance of the survey goes beyond Big Pharma’s finally admitting it has a placebo problem. It also marks the twilight of an era when the drug industry was confident that its products were strong enough to cure illness by themselves.

“Before I routinely prescribed antidepressants, I would do more psychotherapy for mildly depressed patients,” says the veteran of hundreds of drug trials. “Today we would say I was trying to engage components of the placebo response—and those patients got better. To really do the best for your patients, you want the best placebo response plus the best drug response.”

The pharma crisis has also finally brought together the two parallel streams of placebo research—academic and industrial. Pfizer has asked Fabrizio Benedetti to help the company figure out why two of its pain drugs keep failing. Ted Kaptchuk is developing ways to distinguish drug response more clearly from placebo response for another pharma house that he declines to name. Both are exploring innovative trial models that treat the placebo effect as more than just statistical noise competing with the active drug.

Benedetti has helped design a protocol for minimizing volunteers’ expectations that he calls “open/hidden.” In standard trials, the act of taking a pill or receiving an injection activates the placebo response. In open/hidden trials, drugs and placebos are given to some test subjects in the usual way and to others at random intervals through an IV line controlled by a concealed computer. Drugs that work only when the patient knows they’re being administered are placebos themselves.

Ironically, Big Pharma’s attempt to dominate the central nervous system has ended up revealing how powerful the brain really is. The placebo response doesn’t care if the catalyst for healing is a triumph of pharmacology, a compassionate therapist, or a syringe of salt water. All it requires is a reasonable expectation of getting better. That’s potent medicine.

Contributing editor Steve Silberman (steve@stevesilberman.com) wrote about the hunt for Jim Gray in issue 15.08.

1 comment September 9th, 2009

Letter to Senate on health effects of indefinite detention

The Center for Victims of Torture, the Bellevue/NYU Program for Survivors of Torture, and Physicians for Human Rights have sent the following letter to Congress regarding the health effects of indefinite detention:

July 14, 2009

Dear Senator:

We write to you on behalf of the Center for Victims of Torture (CVT), the Bellevue/NYU Program for Survivors of Torture (PSOT), and Physicians for Human Rights (PHR) to impress upon you the substantial health concerns regarding indefinite detention. As the Administration and Congress weigh the possibility of institutionalizing indefinite detention for some detainees the severity of the mental health consequences of indefinite detention must be considered.

Our concerns are based on over 20 years of experience evaluating and caring for thousands of torture victims from all over the world. The current debate regarding the sanctioning of indefinite detention has focused on the legal and moral consequences — that such a scheme is unconstitutional and antithetical to American values. While we appreciate these arguments, we believe that policy makers must also examine the serious medical repercussions of such detention – repercussions that indisputably render indefinite detention to be “cruel, inhuman, and degrading” treatment.

Medical knowledge and experience clearly demonstrate that indefinite detention without charge or trial results in harmful mental health consequences including severe depression and anxiety. This is above and beyond the inherent and already quite substantial stressors of incarceration. [1] In particular, the pervasive uncertainty of prolonged detention results in profound feelings of despair, hopelessness, anger and frustration. Vegetative symptoms, sleep difficulties, suicidal thoughts are common. Profound depression and vegetative symptoms result from realizing nothing that individuals do matters and that there is no way to end, foreshorten or even know the duration of their suffering.

Psychological studies have demonstrated that periods of temporal uncertainty create severe anxiety and feelings of helplessness. [2] Furthermore, research on other populations subjected to forms of indefinite detention, including detained asylum seekers in the United States [3] Britain [4] and Australia  [5], and Japanese-Americans [6]  who endured internment during the Second World War also show the severe burden of suffering that this open ended detention causes. Uncertainty in and of itself poses an additional burden of suffering in the context of chronic illnesses. [7]

Health professionals, including PSOT clinicians who have conducted clinical evaluations of current and former Guantanamo detainees, found that these individuals articulate tremendous despair and hopelessness from not knowing the parameters of their imprisonment. A 2008 study [8] conducted by Physicians for Human Rights in which former detainees from Abu Ghraib and Guantanamo underwent detailed medical and mental health evaluations found that uncertainty was one of the most stressful factors among detainees ultimately released without ever having been charged. This uncertainty resulted in tremendous anxiety, numbing and disconnecting from feelings of hope. Such individuals see no end in sight and no systemic way of understanding their detention. They stop thinking about the future and become highly numb and detached. Attorneys representing Guantanamo detainees have also articulated these concerns.

We are heartened by the new Administration’s and Congress’ support for a complete prohibition of the use of torture and cruel, inhuman, and degrading treatment with respect to prisoners detained by the United States, a prohibition robustly supported by Congress. In light of this framework, it would be incongruous for the Administration and Congress to promote a scheme of detention that induces psychiatric trauma which leaves lasting and severe mental health repercussions. A responsible debate of the prospects of indefinite detention in Congress must include open acknowledgement of the serious medical and health consequences of this scheme of detention in the lives of detainees, and the implications of those consequences under the government’s own prohibition against torture and cruel, inhuman, and degrading treatment under U.S. law and treaty obligations. Simply stated, if we would not want Americans subjected to indefinite detention, we should not subject others to it.

Sincerely,

Allen S. Keller, M.D.
Associate Professor of Medicine, NYU School of Medicine
Director, Bellevue/NYU Program for Survivors of Torture
Director, NYU School of Medicine Center for Health and Human Rights
allen.keller@nyumc.org

Douglas A. Johnson
Executive Director, The Center for Victims of Torture
djohnson@cvt.org

John. C. Bradshaw, J.D.
Washington Director, Physicians for Human Rights
jbradshaw@phrusa.org

Footnotes:

[1] Haney, C. Reforming Punishment: Psychological Limits to the Pains of Imprisonment. 2005. ISBN: 1-59147-317-6

[2] Monat A et al. Journal of Personality and Social Psychology Vol. 24, No. 2,  237. 1972, 248

[3] Keller A et al.  From Persecution to Prison: The Health Consequences of Immigration detention for Asylum Seekers in the U.S. Boston: Physicians for Human Rights, Bellevue/NYU Program for Survivors of Torture. June 2003. available at: http://physiciansforhumanrights.org/library/report-persprison.html

[4] Katy R, Robbins I, Senior V.  Psychological distress amongst Immigration detainees.  British Journal of Clinical Psychology. Vol 48, No. 3. Sept. 2009.  275-286.

[5] Sheikh M. MacIntyre C Perera S. Preventive Detention: The ethical Ground Where Politics and Health Meet. Focus on Asylum Seekers in Australia.  Journal of Epidemiology and Community Health.2008. 62 (6) 480-483.

[6] Potts M. Long-Term Effects of Trauma: Post-Traumatic Stress Among Civilian internees of the Japanese During World War II. Journal of Clinical Psychology. Sept. 1994. Vol 50, No. 5. 681.

[7] Reich J, et al. Uncertainly of Illness Relationships with Mental Health and Coping Processes in Fibromyalgia Patients. Journal of Behavioral Medicine. Vol. 29, No. 4,August 2006. 307-310

[8] Hashemian F et al. Broken Laws, Broken Lives. Medical Evidence of Torture by the U.S. Boston: Physicians for Human Rights.  Available at www.brokenlives.info

July 15th, 2009

Psychiatry tainted by conflicts of interest

USA Today reports on the extensive conflicts of interest at the heart of modern psychiatry, with the vast majority of those involved in developing the latest diagnostic manual [DSM-V] and treatment guidelines for mental disorders having financial ties to drug companies that stand to profit from the results of the work.

One issue not mentioned in the article is the bias in reported studies in which drug studies paid for by drug companies are significantly more likely to find the drug effective than are independently funded studies. This bias, along with others regarding what topics get studied, introduces tremendous uncertainty as to the true scientific basis of modern psychiatry. We will not be able to trust drug studies until the funding for them is taken over by public sources:

Conflicts of interest bedevil psychiatric drug research

By Marilyn Elias

Does it matter if most of the experts who are creating definitions of mental disorders, and standards for the best way to treat them, receive money from pharmaceutical companies?

That question is hotly debated in scientific journals, but it isn’t just academic. It also cuts to the core of public welfare by making it possible for financial profit to affect decisions about who needs treatment, whether they are prescribed medicine and which ones, says Lisa Cosgrove, a psychologist at the University of Massachusetts-Boston.

Critics such as Cosgrove say there’s a damaging conflict of interest in the financial ties between drug companies and leaders who are revising the “bible” of psychiatric diagnoses, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), as well as guidelines on the best treatments.

About 160 experts appointed by the American Psychiatric Association are doing the heavy lifting on the updated manual, expected in 2012. They’re tops in their field, and because industry pays for two-thirds of research, many of them consult for drug companies or do corporate-funded studies, says Darrel Regier, research director for the group. “There’s this assumption that a tie with a company is evidence for bias. But these people can be objective,” he says.

This is the first time the psychiatry association has required members of 13 working groups on diagnoses, as well as the leadership task force, to publicly disclose all industry ties.

FIND MORE STORIES IN: Boston | New England | Columbia University

Sixty-eight percent of task-force members report economic ties with drug companies, Cosgrove says. And of those with links, about four out of five don’t just get research funding, they’re on corporate boards, hold stock or collect money as advisers, she says. She and Harvard Medical School psychiatrist Harold Bursztajn have criticized these ties in The New England Journal of Medicine and Psychiatric Times.

Even small changes in the symptoms for diagnosis of a problem can greatly increase prescriptions for drugs, Cosgrove says, so anyone who could benefit from changes has a potential conflict.

More than half of the members on the 13 working groups also have such ties, according to Cosgrove’s analysis. She says no group should have a majority with drug company links.

But Regier argues: “We want the best people. We don’t want quotas or an artificial litmus test.” He says potential conflicts are limited by a rule that panel members can’t receive more than $10,000 from drug companies while at work on the new DSM.

The $10,000 limit “is not a particularly sensible idea,” says Daniel Carlat, a Tufts psychiatrist who publishes an independent monthly, The Carlat Psychiatry Report, on trends in the field. “They’ve had lucrative relationships in the past, and they know they’re going right back to them.”

Carlat says it’s unrealistic to exclude people with industry-research funding, but he favors limits on those who give promotional talks on drugs, “the real hired guns,” and others with a direct financial interest in firms. “Maybe no more than 30%, maybe no more than 50%. These panels shouldn’t be stacked the way they are now,” he says.

Another flash point: clinical guidelines. Cosgrove led a study on 20 authors of treatment standards for major depression, bipolar disorder and schizophrenia: 90% of them had financial ties to firms that make drugs recommended for the disorder.

But the psychiatry group casts a net to hundreds of reviewers for every guideline, says John McIntyre, who chairs the guidelines committee. The depression and bipolar standards are being updated, “and we’ve gotten thousands of comments online,” Regier says. So any bias gets diluted by diverse voices, McIntyre says; plus, the guidelines are based on evidence.

But there’s the rub, critics say, because drug company-funded studies consistently come out with more positive results for their drug than do independent studies.

“In psychiatry, many diseases are treated equally well with medication or therapy,” Carlat says. “But the guidelines tend to be biased toward medication” because it’s costly to make and study drugs.

Much is at stake. Antipsychotics, which had $14.6 billion in sales last year, were the top-selling class of U.S. medicines; antidepressants brought in $9.6 billion, says IMS HEALTH.

The debate over whether economic self-interest may bias the DSM and treatment guidelines leads to a root issue: Drug companies pay for gathering evidence, and there’s no major alternative on the horizon, says Paul Appelbaum, an expert on ethics in psychiatry at Columbia University. He’s concerned about potential conflicts. But other financing suggestions — for example, companies contributing money for studies run independently by the government — have gone nowhere, he says.

“We’re a capitalist society built on competition, and that has led to many successes,” Appelbaum says. “But this conflict-of-interest issue shows the side effects of the system we have.”

June 3rd, 2009

Mental Health professionals’ letter asks Michelle Obama to investigate diagnostic abuse of veterans

I recently published an article — Diagnostic abuse of veterans and the dilemmas of health professional ethics — [based on reporting by Mark Benjamin and Michael de Yoanna in Salon] on Army pressures for mental health clinicians to not diagnose post traumatic stress disorder [PTSD] in returning soldiers. A group of approximately 130 psychologists and mental health professionals responded to my article by writing Michelle Obama and asking her to look into these charges. Here is their letter:

May 12, 2009

First Lady
Michelle Obama
The White House
1600 Pennsylvania Avenue NW
Washington, D.C.

Dear First Lady,

We are a group of mental health professionals who hope to reach you about an issue concerning the treatment of our veterans.  We are grateful that you have taken an interest in the well-being of veterans and their families, recognizing the weight of responsibility and trauma they may carry during and after service to our country.

In writing we want to call your attention to a concern that official pressures may be interfering with returning soldiers receiving appropriate treatment.  A recent series in Salon by Mark Benjamin and Michael de Yoanna (latest May 5, 2009), reports pressure placed on mental health professionals to under-diagnose Post Traumatic Stress Disorder (PTSD) in returning combat veterans regardless of the clinical reality.  A number of our colleagues who work with veterans have relayed similar experiences of pressure to misdiagnose.

One consequence of this apparent misdiagnosis is that the men and women who served our country do not receive appropriate Veterans’ benefits when their diagnoses do not correctly attribute their emotional problems to their combat experiences. Instead, their problems are attributed either to less severe “anxiety disorders” or to preexisting “personality disorders.”  In addition to potential loss of benefits to which combat veterans are due, misdiagnoses can result in inappropriate treatment and in the veteran being held responsible for part or all of the cost of treatment for conditions caused by combat experience.

As mental health professionals, we are deeply disturbed that pressure is being put upon colleagues to give incorrect diagnoses for reasons antithetical to the best interests of our patients.  Those who suffer serious disorders in the service of our country deserve better.  They deserve the best treatment available.  We are also concerned that this pressure may undermine the ethical foundation upon which the mental health professions are based.

We have included an essay by Dr. Stephen Soldz, co-founder of the Coalition for an Ethical APA and Steering Committee Member of Psychologists for Social Responsibility, which we believe sheds important light on this subject.

We ask you to look into this matter and related issues concerning the mental health treatment of our soldiers and veterans.  We are willing to assist you in any ways we can in this endeavor.

With respect and regards,

Alice Lowe Shaw, Ph.D.
President-Elect Section IX, Division 39
Psychoanalysis and Social Responsibility

Stephen Soldz, Ph.D.
Director, Center for Research, Evaluation and Program Development
Boston Graduate School of Psychoanalysis

Psychologists for Social Responsibility (PsySR), organizational endorsement
700+ members

Thomas Rosbrow, Ph.D.
Psychoanalytic Institute of Northern California (PINC)
San Francisco

Marilyn S. Jacobs, Ph.D., ABPP
David Geffen School of Medicine at UCLA
Dept. of Psychiatry and Biobehavioral Sciences
Los Angeles

Melanie Suchet, Ph.D.
Stephen A. Mitchell Center for Relational Studies
New York City

Lynne Layton, Ph.D.
Harvard Medical School
Cambridge, Massachusetts

Katie Gentile, Ph.D.
Women’s Center Director
John Jay College of Criminal Justice
New York City

Karen Rosica, Psy.D.
Denver, Colorado

Richard Reichbart, Ph.D.
Institute for Psychoanalytic Training and Research (IPTAR)
Ridgewood, N.J.

Rachael Peltz, Ph.D.
PINC
San Francisco

Elizabeth Hirky, Ph.D.
Senior Psychologist
Bellevue Hospital Center
New York City

Julie Gerhardt, Ph.D.
PINC
San Francisco

Ruth Fallenbaum, Ph.D.
Berkeley,  California

Nina K. Thomas, Ph.D., ABPP
NYU Postdoctoral Program in Psychotherapy and Psychoanalysis
New York City

Susan Gutwill, MS, LCSW
Highland Park, New Jersey

Diane Ehrensaft, Ph.D.
Oakland, CA

Brad Olson, Ph.D.
Northwestern University
Evanston, Illinois

Susan Phipps-Yonas, Ph.D., L.P.
Minneapolis, MN

Lorri Greene, Ph.D.
San Diego, CA

Ryan Hunt

Connie Evert, Ph.D.
Philadelphia

Leni de Mik, Ph.D.
Minneapolis, MN

Larry Welkowitz, Ph.D.
Keene State College,
Keene, New Hampshire

Frank Summers, Ph.D., ABPP
Northwestern University
Chicago, Il

Jeanne Wolff Bernstein, Ph.D.
Berkeley, CA

Kenneth Feiner, Ph.D.
NYC

Jancis Long, Ph.D.
President, Psychologists for Social Responsibility
Berkeley, CA

John Neafsey, Psy.D.
Chicago, Il

Thomas S. Greenspon, Ph.D.
Minneapolis, MN

Stephen Botticelli, Ph.D.
NYC

Loren Krane, Ph.D.
UCSF Dept of Psychiatry
San Francisco

Trudy Bond, Ph.D.
Toledo, OH

Armond Aserinsky, Ph.D.
North Wales, PA

Muriel Dimen, Ph.D.
NYC

Donna Bassin, Ph.D.
Secretary APA Division 39, Section IX

Ellen G. Levine, Ph.D., M.P.H.
Castro Valley, CA

Anthony J. Marsella, Ph.D.
Past President, PsySR

Polly Scarvalone, Ph.D.
NYC

Cynthia Colvin, Ph.D.
PINC
Oakland, CA

Laurel Bass Wagner, Ph.D.
Dallas, TX

Stefan R. Zicht, Psy.D.
NYC

Helene Goldberg, Ph.D.

Stephen Benson, Ph.D.
Blue Hill, ME

Maureen Murphy, MSN, Ph.D.
San Francisco

Virginia Goldner, Ph.D.

Nancy Burke, Ph.D.
Northwestern University
University Medical School
Chicago, Il

Elizabeth Hegeman, Ph.D.
Professor John Jay College of Criminal Justice
William A. White Institute
NYC

Leigh Messinides, Ph.D.
Tustin, CA

Peter Shabad, Ph.D.
Chicago

Ann B. Clarkson, Ph.D.
Portland, OR

Mary-Joan Gerson, Ph.D.

Sonia Orenstein, Ph.D.
NYC

Jill Bellinson, Ph.D.
NYC

Stephen Portuges, Ph.D.
Executive Editor, International Journal of Applied Psychoanalytic Studies
Los Angeles

Andrew Tatarsky, Ph.D.
Past president, Division on Addiction,
New York State Psychological Assn.
NYC

Susan Bodnar, Ph.D.
NYC

Todd Essig, Ph.D.
William Alanson White Institute
NYC

Sharon Brennan, Ph.D.

Christy Paliouras, Ph.D.
Astoria, NY

Maureen C. Grix, Ph.D.
The Suffolk Institute
Garden City,  NJ

Maureen O’Reilly-Landry, Ph.D.
Columbia College of Physicians and Surgeons
NYC

David Sloan-Rossiter, Ph.D.
Brookline, MA

Steven Reisner, Ph.D.
NYC

David Thurn, LMSW, PH.D.
NYC

Richard Lasky, Ph.D.
Clinical Professor of Psychology
NYU Post-Doctoral Program in Psychotherapy and Psychoanalysis
NYC

Elaine Gould, Ph.D.
New York

Susan Katz

Richard B. Gartner, Ph.D.
NYC

Eric W. Anders, Ph.D., Psy.D.
Institute of Contemporary Psychoanalysis
Oakland, CA

Linda R. Laughlin, Ph.D.

William A. MacGillivray, Ph.D., ABPP,
University of Tennessee,
Knoxville, TN

Kathryn G. White, Ph.D.
New Haven, CT

Katie L. Fitzpatrick, M.A.
University of Tennessee

Knoxville, TN

Dana Satir, M.A.
Center for Anxiety and Related Discord
Boston, MA

Kathleen W. Erickson, LCSW
(mother of an Iraq War veteran)
Knoxville, TN

Robert K. Albiston, Ph.D.
Past President, Appalacian Psychoanalytic Assn.
Knoxville, TN

Edward R. Ryan, Ph.D.
New Haven, CT

Mila R. Tecala, Lic. SW
Washington, D.C.

Greta H. Gustafson, LCSW
NYC

Mark S. Kane, Ph.D.
Michigan

Margaret L. White, Ph.D.
Upper Montclair, NJ

Christine A. Chapman, LCSW

Cathy S. Nelson, LISW
Ames, IA

Adrienne Harris, Ph.D.
NYC

Erika Vadopalas, LMFT
Coming Home Project
San Carlos, California

Annita Sawyer, Ph.D.
Yale Medical School
New Haven, CT

Steven H. Knoblauch, Ph.D.
NYC

Andrew M. Barclay, Ph.D.

Cathie Bird, MA, Psy.D.
Pioneer, TN

Debra Rothschild, Ph.D.
NYC

Luz Towns-Miranda, Ph.D.

NYC

Darlene DiGorio-Hevner, MA, MSW, LCSW
Ardmore, PA

Arlene Lu Steinberg, Ph.D.
Columbia University
NYU

Don Greif, Ph.D.
William Alanson White Institute
NYC

Spyros D. Orfanos, Ph.D., ABPP
Clinic Director
NYU Postdoctoral Program in Psychotherapy and Psychoanalysis
NYC

Barbara Eisold, Ph.D.
Yeshiva University
NYC

Barbara Blasdel, Ph.D.

Susan R. Greene, Ph.D.
San Francisco Center for Psychoanalysis (SFCP)

Candy Siegel, Ph.D.
Tucson, Arizona

Carolyn Ellman, Ph.D.
IPTAR, NYU Postdoctoral Program
NYC

Robert Keisner, Ph.D.
Professor of Psychology
CW Post/Long Island University
Brookville, NY

Maria T. Russo, Ph.D.
East Hampton, NY

Jerome Siller, Ph.D., ABPP
NYC

Scott W. Smith, M.A.
Doctoral Candidate
Adelphi University
New York

Martha Davis, Ph.D.
Visiting scholar, John Jay College of Criminal Justice
NYC

Stephen J. Ducat, Ph.D.
San Francisco

Debra A. Lopez, MD
Clinical Associate Professor
University of Vermont Dept of Psychiatry
Burlington, VT

Jeffrey F. Johns, MD (former Air Force Psychiatrist)
Oakland, CA

Barbara F. Marcus, Ph.D.
Yale University School of Medicine
Vice President, Board of Trustees and Faculty,
The Western New England Institute of Psychoanalysis
New Haven, CT

Sergio Rothstein, Ph.D.
NYC

Lawrence O. Brown, Ph.D.
Fellow Supervisor of Psychotherapy and Teaching Faculty
William Alanson White Institute
NYC

David G. Byrom, Ph.D.
Co-Director, Family Therapy Institute of Suffolk
Smithtown, NY

Juliet M. Ross, Psy.D.
NYC

Andrew B. Sieff, A.P.N., PMHCNS-BC
Psychiatric Clinical Nurse Specialist
Fayetteville, AR

Mildred Antonelli, Ph.D.
Institute for the Psychoanalytic Study of Subjectivity
NYC

Herbert Gingold, Ph.D.
Co-Founder of the Noir Institute
Kew Gardens, NY

Marc Pilisuk, Ph.D.
Professor Emeritus, The University of California
Professor, Saybrook Graduate School and Research Center
Berkeley, CA

Sharon L. Windwer, Psy.D.
Little Neck, NY

Bonnie J. Lipeles, Psy.D.

Margit Winkler Ph.D.
Supervising Analyst, Wm. Alanson White Institute

Lydia Seggev

Susan Lillich, Ph.D.
Williston, VT

Jules Burnstein, Ph.D.

Ronna Friend, Ph.D.
Eugene, Oregon

Cornelia St. John, MFT
Oakland, CA

Claire Hertz
Institute for Contemporary Psychotherapy
NYC

Linda Schrader, Ph.D.
Bend, OR

Jeff Kaye, Ph.D.
Clinician, Survivors International
San Francisco

Gerald Gray, LCSW
Founder, Center for Justice and Accountability
San Francisco
Co-Founder Institute for Redress and Recovery
Santa Clara University Law School

Philip Hill, Ph.D.

Latika Mangrulkar, MSW, ACSW

Jean Maria Arrigo, Ph.D.

Jonathan Wormhoudt, Ph.D.

Elliot Jurist, Ph.D.

Skye Haberman, Ph.D.

Joanie V. Connors, Ph.D.

Stephen Seligman, D.M.H.
University of California, San Francisco

May 18th, 2009

Wounds of war remain forever, psychologist-veteran argues

Psychologist Armond Aserinsky wrote very movingly to a listserv of his experience as a young veteran conducting interviews with other veterans recently returned from war. His writing highlights the severe emotional toll that war takes on the soldiers we send to fight. Armond has kindly given me permission to reproduce his piece here:

Dear group,

As a recently discharged veteran of the Vietnam War and brand new Psych Grad Student I was offered a special research assistantship that required me to interview the gravely injured soldiers undergoing treatment at The Valley Forge Military Hospital, in Phoenixville, Pennsylvania. Talk about jumping into the pool at the deep end without having had any swimming lessons. But the project leader needed my understanding of and credibility with the military to gain access to this very “sensitive” population.

Let me say that the lessons I learned over those months have never been forgotten. While I know a lot more now than I did back then (in a lot of ways), I’ve never come to regard those raw observations as wrong. What I saw, in a nutshell, is that the military tried to do a very good job patching those young soldiers together PHYSICALLY, but the mental health aspects were woefully undertreated.

During the acute phase of hospitalization, and the months of convalescent hospital care, some efforts were made to engage the patients in various kinds of support groups. While the expertise of the fellow heading up the MH side of the clinical team was well below that of the medical members, that young social worker was a very brave and compassionate man who did some real good. The real problem was not at this point in the treatment process.

What was wrong, and still is, was the complete lack of recognition that these soldiers’ lives had been permanently derailed. The sense of loss, the unremitting nature of the injuries, comes to have a grinding, corrosive effect on the sense of self, on coping, on relationships. What bullets have torn apart is often never really put together, and every wound to the flesh has a mental counterpart that festers in the darkness of denial and ignorance.

I know that today’s soldiers receive miraculous treatments for injuries that killed their predecessors in the field. Yet one gets the same impression now that I had way back when: an injured serviceman is offered “help if he should need it”, as if MH sequela were rare and rather unexpected. Instead of a lifetime program of benefits and active support, the soldier receives a set of patches when obvious tears in his physical or mental fabric develop. “Oh, so you’re drinking a case of beer a night? We’ve got a D & A counselor you can see down here at the V. A.”

Of course the damage to minds is not limited to those who’ve been shot up or partially blown apart. That’s what the letter to Mrs. Obama is meant to address. What I’m proposing is that just about everyone who’s had to be stitched together ought to be regarded as an MH casualty in need of some system of support that doesn’t require a fellow to shoot somebody or fall down drunk before a sliver of help is offered. For those who were lucky enough to get through the bloodbath in one piece, the numbers are only slighter better.

We owe it to take real care of each person who Dick Cheney and all the other chicken hawks sent out to fight their foolish wars. Real care means recognizing up front that if you were “over there” you’re going to have problems, because that’s the nature of being human.

I hope I’m making myself clear. I still carry some wounds from just being involved with the young men who gave their arms and legs for an unnecessary war and were then sent home to limp and ache and suffer for the rest of their lives, as if it were no big deal. “Come back and see us if you’re having problems.”

If. IF?! IF?!

May 9th, 2009