Shrinking the News

A column by Peter Sheehy

"But my dear man, reality is only a Rorschach ink-blot, you know" -Alan Watts

Suicide Watch

Last Thursday's New York Times notes that the Food and Drug Administration is reversing its decades-long habit of failing to investigate potential psychiatric side effects of medicines. But while the new rules requiring suicide studies are long overdue and a positive step, it is unclear what consumer protections the new rules provide because FDA procedures for evaluating experimental drugs are secret.

Drug makers, however, have received notification from the FDA alerting them to the fact that they must now implement suicide assessment analysis in their clinical trials.

The impetus for this important change came as a result of research conducted by Columbia University’s psychiatry department, under the direction of Kelly Posner, Ph.D. In 2004, the FDA learned that some children taking anti-depressants had become increasingly suicidal, but the FDA remained unconvinced of a definitive link between anti-depressants and suicidal ideation until the Columbia studies confirmed it. Similar studies with a French obesity drug – rimonabant – also motivated the agency to develop a clear policy on testing for psychiatric side-effects. Now, the agency embraces a Suicidality Classification Project.

According to the New York Times, “there are two reasons that the F.D.A. for years was inattentive to the psychiatric effects of new medicines. First, distinguishing between mental problems that spring from a disease and those that result from its treatment is often difficult. For antidepressants, many researchers suggested that suicidal behaviors resulted because, as patients’ depression lifted, they suddenly had the energy to carry out previous suicidal thoughts. Second, drug side effects are often first identified in clinical trials when multiple doctors treating hundreds of patients record similar problems in trial notes. But terms to describe depression or suicidal thoughts can vary widely, making them hard to discern.”

Some related stories include:
-Tamiflu, Relenza Side Effects Need Listing
- Tamiflu And Relenza Should Have Psychiatric Side Effects Warning, Say Regulators
- FDA: Weight-Loss Drug Could Cause Suicidal Thoughts
-Ritalin, Concerta possibly linked to psychiatric problems

On a related note, representatives Henry A. Waxman, John D. Dingell, Frank Pallone, Jr., Rosa L. DeLauro, and Edward Markey, and Senators Edward M. Kennedy, Patrick J. Leahy, and Christopher J. Dodd, are skeptical about a new Food and Drug Administration (FDA) proposal because it appears that it is designed to shield pharmaceutical corporations from consumer lawsuits.

A statement posted on Waxman’s House Oversight and Government Reform Committee states that the “FDA’s proposed rule would amend the regulations that permit companies to promptly update their drug and device labels with new safety information without waiting for FDA approval. These regulations serve the vitally important public health function of ensuring that patients and healthcare providers are made aware of safety risks associated with their medical products at the earliest possible moment.”

In a letter to the FDA, also available on Waxman’s site, the lawmakers assert that “We are concerned that the intent of this proposal is to protect companies in the pharmaceutical and device industry from being held liable for marketing products they know are unsafe” and that “such a policy change comes at the expense of consumers and violates the mission of the FDA.”

Shrinking the News is a column written by Peter Sheehy, who earned a PhD from the Department of History at the University of Virginia. His dissertation is on the cultural history of psychotherapy. Dr Sheehy teaches history at the Horace Mann School in New York City and is working on a book about the history of psychotherapy.

Shrinking The News

A column by Peter Sheehy

"But my dear man, reality is only a Rorschach ink-blot, you know" -Alan Watts



A Debt That Haunts...

During his second night in Iraq in October of 2003, Sergeant Andreas Pogany witnessed an Iraqi man cut in half by a machine gun. Pogany vomited, shook for hours, and by his own confession, “couldn’t function.” Despite Pogany’s insistence that he was having panic attacks, he was denied proper therapeutic care and was eventually sent home. Before long, Pogany faced court-martial for cowardice, a charge the military had not pursued since the Vietnam war, and one that carries a maximum sentence of death.

Although the military eventually dropped the charges against Pogany, the government's neglect of combat traumas is a bad flashback to the Vietnam era. Even worse, it's a denial of the therapeutic practices that our armed forces developed during World War II. Turning its back on our soldiers' psychiatric wounds, today's military is also rejecting its own history.

Given the administration’s belief that “shock and awe” was a fitting strategy for the war, its lack of preparation for the “shell shock” and disorientation that followed is not surprising. Just eighteen months after President Bush declared "Mission Accomplished" in Iraq, The New England Journal of Medicine reported that one sixth of all U.S. veterans of the Iraq war were suffering from post-traumatic stress or depression. Even the Army’s own study found that 30% of soldiers currently serving in Iraq display symptoms of anxiety, depression, and post-traumatic stress.

The number of veterans from Iraq and Afghanistan who have struggled with post-traumatic combat stress (a modern variation of “shell shock” that is perhaps the most serious psychological wound for a soldier), will soon reach 45,000. And that number is sure to rise since repeated tours increase the chances of acute combat stress by 50%. The unfolding of the President’s surge plan is thus an appropriate time to contemplate the devastating psychological wounds of this war and adjust our policies by remembering how the “greatest generation” cared for the psychological wounds of its men in uniform.


Many of the psychological wounds from the present war are still as invisible to the public as the caskets of our dead soldiers. The Pentagon's public relations and limited “therapeutic” strategies have marginalized our veterans’ painful memories of a war we would like to forget, but continue to wage. Sadly, recent news reports show that the government and military have been stigmatizing and even punishing psychiatric casualties, undermining treatment plans with bad science, and inadequately funding therapeutic programs.

Present policies have brought us back to a pre -World War II standard of care. During that war, the Roosevelt administration provided therapeutic treatment and preventative care to more than two million soldiers. William and Karl Menninger, the main architects of wartime and post-World War II psychiatry, knew that American GIs needed more than a stiff upper lip to overcome what they called “combat exhaustion” and “war neurosis.”

World War II experts responded by demolishing the stigmas attached to mental illness and helped millions of Americans understand that fear in combat was normal and that seeking help was productive and responsible, not shameful. These actions helped modernize psychiatry by pulling it out of an era of institutionalized care, and establishing that the stress of war could break down even the most well-adjusted individuals.

The "greatest generation" had no tolerance for General Patton’s ignorant rejection of military psychiatry. When Patton slapped a “psychiatric casualty” across the face, officials forced the general to apologize and then stripped him of his command.

Unfortunately, the enlightened standard of therapeutic care established during World War II was ignored during the Vietnam war. The emotional suffering of our veterans from this war has been seared into the public consciousness by films such as The Deer Hunter and Full Metal Jacket. The government finally officially recognized post traumatic stress disorder in 1980, yet many of the commanders treating soldiers in this war do not even support the diagnosis.

Today, Americans worship the "greatest generation" of World War II soldiers. We admire their grit and determination in defeating the fascist enemy. But we forget how much they suffered along the way, and the enormous role that psychiatry played in helping them survive battle and come home with support and dignity. It's time for all of us to remember, before it's too late.

Shrinking the News is a column written by Peter Sheehy, who earned a PhD from the Department of History at the University of Virginia. His dissertation is on the cultural history of psychotherapy. Dr Sheehy teaches history at the Horace Mann School in New York City and is working on a book about the history of psychotherapy.

Shrinking The News...

A column by Peter Sheehy

"But my dear man, reality is only a Rorschach ink-blot, you know"
-Alan Watts


Congratulations to Boston psychiatrist Jonathan Shay, who last week received a MacArthur Foundation “genius award” for his "for his pioneering work in using literary parallels from Homer's 'Iliad' and 'Odyssey' to treat combat trauma suffered by Vietnam veterans.












Shortly after beginning work at the Department of Veteran Affairs in 1987, Shay noticed that the psychological trauma suffered by Vietnam Veterans was eerily similar to the psychological devastation that plagued the warriors in ancient Greek epics such as Homer’s Illiad and Odyssey. Shay asserts that "as long as human beings go to war and try to come home from war, these [epics] will speak to us," because "they truly hold up all that is generic about going to war and coming home from war. . . There will never be a war where people don't get hurt psychologically."

(Note: Shay prefers to use the term “psychological injury” or “combat trauma” rather than the DSM terminology of post traumatic stress disorder (PTSD). The latter, he believes, is stigmatizing, while the former does not distinguish mental and psychical wounds.)

The MacArthur Fellows Program describeds Dr Shay as “important for delivering healthcare to all those who put their lives on the line in the service of our country” is “a passionate advocate for veterans and committed to minimizing future psychological trauma,” and one who “strives for structural reform of the ways the U.S. armed forces are organized, trained, and counseled.”

Amen.

Click here to listen to Shay on NPR discussing a scene in the Odyssey and how it relates to the war in Iraq.

Click here to watch Shay interviewed by the Macarthur Foundation

Shrinking the News is a column written by Peter Sheehy, who earned a PhD from the Department of History at the University of Virginia. His dissertation is on the cultural history of psychotherapy. Dr Sheehy teaches history at the Horace Mann School in New York City and is working on a book about the history of psychotherapy.

Shrinking The News...

A column by Peter Sheehy

"But my dear man, reality is only a Rorschach ink-blot, you know"
-Alan Watts

If “The Third Time is a Charm,"
Why are We Still Failing our Wounded Soldiers?

This morning the Subcommittee on National Security and Foreign Affairs held a hearing, "Third Walter Reed Oversight Hearing: Keeping the Nation's Promise to Our Wounded Soldiers."

Despite some progress since the previous two hearings, the theme, at least in the questioning from Representative Waxman (D-CA) (chairman of the Committee on Oversight and Government Reform) was more about broken promises.


In questioning Michael Dominguez, the Principal Deputy Under Secretary of Defense for Personnel and Readiness, Waxman discussed a soldier who was redeployed despite his need for "psychiatrically limiting medication," and also outlined ways in which the Department of Defense's own redeployment procedures were not being followed. Waxman described the "systemic problems" of wrongful discharges of soldiers with psychiatric conditions that are caused by the military's refusal to accept the reality that many soldiers' mental health problems are combat-related.

In one shocking exchange, Waxman cited a memo obtained by NPR from the Director of Mental Health at Evans Army Community Hospital who has authored a manual on care for soldiers, that declared "we can't fix every soldier" and "neither can you." "Everyone in life has to be held accountable for what they do in life," so "get rid of the dead wood." Waxman concluded his testimony by insisting that the military stop blaming Post Traumatic Stress Disorder (PTSD) on previous conditions, and thus stigmatizing soldiers with dishonorable discharges that will also limit their ability to seek VA care.

I would be interested to know how many of these vets end up in your Emergency Department?

For the Government Accountability Office Report on Health Care for Service members see GAO Testimony Before the Subcommittee on National Security and Foreign Affairs, Committee on Oversight and Government Reform, House of Representatives.

See NPR's outstanding series on PTSD and mental health care for soldiers .

Click here for video coverage of today's hearings.

Shrinking the News is a column written by Peter Sheehy, who earned a PhD from the Department of History at the University of Virginia. His dissertation is on the cultural history of psychotherapy. Dr Sheehy teaches history at the Horace Mann School in New York City and is working on a book about the history of psychotherapy.

A column by Peter Sheehy

"But my dear man, reality is only a Rorschach ink-blot, you know" -Alan Watts

A Stressful Failure

According to its own internal reports, the Department of Veterans Affairs is failing our soldiers and is unable to meet even its own internal standards of care for post-traumatic stress disorder (PTSD).

McClatchy’s sobering study of PTSD care for troops shows that

“nearly a third of the agency's inpatient and other intensive PTSD units failed to meet at least one of the quality goals monitored by a VA health-research organization.”

The VA is also being scrutinized for understaffing and insufficient funding in mental health units. Though the VA has defended its track record with psychologically wounded vets, it removed its reports from its WWW site and thus McClatchy had to obtain its information through the Freedom of Information Act.

Paul Sullivan, a former VA official who now works for Veterans for Common Sense said that the surge of veterans needing is care is part of an "ominous trend” that if “continued will transform the VA's crisis into a full-blown catastrophe”.

For more on PTSD, click here



Shrinking the News is a column written by Peter Sheehy, who earned a PhD from the Department of History at the University of Virginia. His dissertation is on the cultural history of psychotherapy. Dr Sheehy teaches history at the Horace Mann School in New York City and is working on a book about the history of psychotherapy.

Shrinking the News...

A column by Peter Sheehy

"But my dear man, reality is only a Rorschach ink-blot, you know" -Alan Watts



Homosexuality on the Couch
Today the Detroit Free Press is reporting that the American Psychological Association is beginning a review of policies on “reparative therapy” or “conversion therapy.” These controversial therapies are designed to change a patient’s sexual orientation.

Though the Bush administration’s nominee for Surgeon General (Dr. James W. Holsinger) is a proud homophobe who authored a "scientific" paper titled "Pathophysiology of Male Homosexuality," (see yesterday's column) current American Psychological Association policy opposes treatment that regards homosexuality as a mental illness. In 1997 the American Psychological Association Council of Representatives passed a resolution on “reparative” therapy that

"urge[d] all mental health professionals to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientation."

The American Psychiatric Association issued a similar statement in 1998 through its Board of Trustees.

In 1973 the American Psychiatric Association removed homosexuality from a list of mental disorders in the DSM. This decision, which was undoubtedly influenced by the gay rights movement, has been criticized by politically conservative psychiatrists and psychologists as an example of how scientific principles can be sacrificed to political agendas. These same arguments have re-emerged with the American Psychological Association’s exclusion of “certain conservative applicants” from the committee reviewing “reparative therapy” or “conversion therapy” because of their “fundamentally negative religious perceptions of homosexuality."

The American Psychological Association’s director of the Lesbian, Gay and Bisexual Concerns Office (Clinton Anderson), has stated that the panel’s report would be grounded in scientific research rather than ideology.

While I hope that the American Psychological Association adopts a critical stance towards “reparative” or “conversion” therapies (yet allows those patients who desire such treatment to receive it, especially since talk therapy is based on free speech and the process by which patients re-describe themselves according to the dictates of their own imagination and conscience) I am not sure that defending such policies in the hallowed ground of science is entirely honest or necessary.

We should applaud the extent to which our culture’s increasingly more enlightened view of homosexuality has shaped medical experts’ approaches to homosexuality. There is nothing wrong with culture informing the clinical gaze. Thomas Kuhn taught us this decades ago in his magisterial The Structure of Scientific Revolutions .

The recently deceased philosopher Richard Rorty, one of the most original public intellectuals of the past thirty years, articulated a vision of a tolerant and diverse community committed to opposing cruelty (see Contingency, Irony and Solidarity ). The values of such a community -- one that surely respects the rights and dignity of homosexuals -- are determined not by claims to epistemological or scientific truths, but to pragmatic debates about the cruelty of certain social practices and the need for human solidarity.

For Rorty, it would be pointless to defend the dignity of homosexuals in scientific terms when it is enough to simply state that we all have an obligation to reduce suffering and obvious bigotry. In this case, the cruel stigmatizing of homosexuality as an identity that requires eradication through psychological or psychiatric care perpetuates suffering and destroys human dignity.

Shrinking the News is a column written by Peter Sheehy, who earned a PhD from the Department of History at the University of Virginia. His dissertation is on the cultural history of psychotherapy. Dr Sheehy teaches history at the Horace Mann School in New York City and is working on a book about the history of psychotherapy.