Thursday, May 16, 2013
May 15, 2013
By JAMES DAO and ANDREW W. LEHREN
After Specialist Freddy Hook, a medic with the Army’s 82nd Airborne Division, killed himself in 2010, the trail of possible causes seemed long.
He had used illegal drugs: Was it the demons of addiction? His rocky relationship with his fiancée? A wrenching deployment to earthquake-ravaged Haiti or the prospect of an impending tour in Afghanistan?
As with most of suicides plaguing the military today, no one will know for sure.
“There are so many factors,” said his mother, Theresa Taylor, of Lafayette, La. “Everything that was important to him was having problems.”
Of the crises facing American troops today, suicide ranks among the most emotionally wrenching — and baffling. Over the course of nearly 12 years and two wars, suicide among active-duty troops has risen steadily, hitting a record of 350 in 2012. That total was twice as many as a decade before and surpassed not only the number of American troops killed in Afghanistan but also the number who died in transportation accidents last year.
Even with the withdrawal from Iraq and the pullback in Afghanistan, the rate of suicide within the military has continued to rise significantly faster than within the general population, where it is also rising. In 2002, the military’s suicide rate was 10.3 per 100,000 troops, well below the comparable civilian rate. But today the rates are nearly the same, above 18 per 100,000 people.
And according to some experts, the military may be undercounting the problem because of the way it calculates its suicide rate.
Yet though the Pentagon has commissioned numerous reports and invested tens of millions of dollars in research and prevention programs, experts concede they are little closer to understanding the root causes of why military suicide is rising so fast.
“Any one variable in isolation doesn’t explain things,” said Craig J. Bryan, associate director of the National Center for Veterans Studies at the University of Utah. “But the interaction of all of them do. That’s what makes it very difficult to solve the problem. And that’s why we haven’t made advances.”
An emerging consensus among researchers is that, just as among civilians, a dauntingly complex web of factors usually underlie military suicide: mental illness, sexual or physical abuse, addictions, failed relationships, financial struggles. Indeed, the most recent Pentagon report of suicides found that half of the troops who killed themselves in 2011 had experienced the failure of an intimate relationship and about a quarter had received diagnoses of substance abuse.
Studies have also found that certain patterns of suicide among civilians seem intensified within the military. Among civilians, young white males are one of the most likely groups to kill themselves. In the military that group, which is disproportionately represented, is even more likely to commit suicide. Among civilians, firearms are the most common means; in the military, as might be expected, guns are used even more often, in 6 of every 10 instances.
Deployment and exposure to combat can act as catalysts that worsen existing problems in a service member’s life, like drug abuse, or cause new ones, like post-traumatic stress disorder or traumatic brain injuries, which may contribute to suicidal behavior. Indeed, a study published this week in the medical journal JAMA Psychiatry found that troops with multiple concussions were significantly more likely to report having suicidal thoughts than troops with one or no concussions.
Yet deployment and combat by themselves cannot explain the spiking suicide rates, researchers say. Pentagon data show that in recent years about half of service members who committed suicide never deployed to Iraq or Afghanistan. And more than 80 percent had never been in combat.
“This probably is the keenest misconception the public has: that deployment is the factor most related to the increased rates of suicide,” said Cynthia Thomsen, a research psychologist at the Naval Health Research Center in San Diego.
Another question lingers: Is the current trend unique, or typical of war throughout the ages? Because detailed data on military suicides was not collected until after Vietnam, it is impossible to know, though many experts believe that suicides rose during and after the two World Wars, Korea and Vietnam.
What is known is that since 2001, more than 2,700 service members have killed themselves, and that figure does not include National Guard and reserve troops who were not on active duty when they committed suicide.
Suicide among veterans has also risen somewhat since 2001, to an estimated 22 a day, according to the Department of Veterans Affairs.
Just 12 years ago, when the rate of military suicide was so much lower, many experts believed that military culture insulated young people from self-harm. Not only did it provide steady income and health care, structure and a sense of purpose, the reasoning went, military service also screened personnel for criminal behavior as well as for basic physical and mental fitness.
But a decade of war has changed that perception.
“There is a difference between a military at war and a military at peace,” said Dr. Jonathan Woodson, assistant secretary of defense for health affairs. “There is no doubt that war changes you.”
The Loved Ones’ Question
The Pentagon’s 2011 annual report on suicide, the most recent available, paints this picture: About 9 of 10 suicides involved enlisted personnel, not officers. Three of four victims did not attend college. More than half were married. Eight in 10 died in the United States. Most did not leave notes or communicate their intent to hurt themselves.
Each of those suicides comes with its unique set of circumstances, its own theory as to why. But in the voices of loved ones left behind, themes echo. Surprise. Confusion. A relentless question: Could we have done more?
Cpl. Wade Toothman of the Marine Corps deployed to Iraq, where a good friend was killed, and then to Afghanistan, where a roadside bomb blew out one of his eardrums.
After he left the Marines in 2011, he complained of chronic headaches, a possible symptom of a traumatic brain injury. But he did not seek treatment. His mother also worried that he had post-traumatic stress. But he denied it and refused to see a doctor, saying he feared that the diagnosis would make it impossible to get a job. “People will say I’m crazy,” he told her.
Experts say the months just after a service member leaves the military can be a particularly disorienting and even dangerous time. Once cocooned in close-knit units, new veterans must learn to be individuals again, freer yet often more alone, surrounded by a society that knows little about military life.
Once back in his tiny Oklahoma hometown, Prue, Corporal Toothman got bored and moved to Hawaii, where he had been based. But he could not find work, returned to Oklahoma, took a prison-guard job that he hated and talked idly of re-enlisting.
“He was having a hard time being a civilian,” said his mother, Louise Toothman.
She did not realize just how hard. One October weekend in 2012, she went with her son to shop for groceries and pick up the tags for his new pickup truck. He seemed content. “He was making plans,” she said.
Two days later, he killed himself with a shotgun she had given him as a gift.
After his death, she began to uncover clues. Medical records showed that despite his denials about post-traumatic stress, the Marine Corps had treated him for the disorder, including by prescribing him antidepressants.
He also left behind an anguished note that made his mother believe he could not forget seeing a close friend killed in Iraq. “I’ve held a lot of guilt and anger and sadness inside for a very long time,” he wrote her. “I was too ashamed and proud to say it to you.”
“I stopped drinking and tried dealing with it on my own and I failed,” he continued. “I’m sorry I let you down. I was really hoping for some crazy, noble, heroic death. I love you and there’s nothing you or anyone could do. This is my decision. I’m sorry I wasn’t strong enough.”
Ms. Toothman wept as she read his words. “If I had known these things, I would have acted differently,” she said. “I would have been right there.”
Don Lipstein knows that feeling.
His son, Petty Officer Second Class Joshua Lipstein, had been a heavy drinker as a teenager growing up in Wilmington, Del. But motivated by the Sept. 11 terrorist attacks four years earlier, he enlisted in the Navy and joined a riverboat crew that seemed to give him a sense of fulfillment, his father said. He made plans to make the Navy a career.
But during his second Iraq tour, doctors discovered he had a brain tumor and sent him home. In late 2009, he underwent surgery that caused him to lose hearing in one ear. Assigned to a desk job, he seemed headed for a medical discharge. The prospect of losing a career he loved was wrenching.
In the ensuing months, his father recalls, he became dependent on opioid pain killers. He told his father he was not addicted, just self-medicating. But Mr. Lipstein pushed him to enroll in a drug rehabilitation program. It did not help: months afterward, Petty Officer Lipstein started using heroin.
Even the birth of a daughter did not seem to relieve his inner struggles. In March 2011, while he was awaiting his final discharge, he spoke to his father on the phone. Mr. Lipstein could hear the despondency; alarmed, he asked his son to unload his gun.
“Dad,” he replied, “I can’t do that.” He killed himself soon after.
Mr. Lipstein, who speaks and counsels about suicide for the Tragedy Assistance Program for Survivors, a nonprofit organization, says he does not blame the military for his son’s death, noting how much he loved his work.
But he wonders whether commanders missed telltale signs — a problem the Pentagon acknowledges may be widespread. He wonders if he missed them, too.
“I didn’t look at him as suicidal,” he said. “Looking back, there were all kinds of stressors on his life. If I could have considered he was suicidal, could I have done something to prevent it?”
Looking for What Works
For Kathryn Robinson, seeking treatment for her post-traumatic stress disorder and occasional thoughts about suicide was not an issue. Finding a program that worked was.
A member of the Army National Guard, she deployed to Iraq in 2007 as a combat videographer. There, a sniper shot off one of her fingers during a fierce firefight. After active duty, she isolated herself from friends and family and became dependent on antidepressants.
But unlike some veterans, Ms. Robinson, 45, who lives in Detroit, sought treatment repeatedly: a residential program for post-traumatic stress disorder, a women’s trauma recovery program, horse therapy, songwriting therapy, transcendental meditation, running.
Travel seems to work best of all, she said: “I call it trying to outrun the crazy.”
Under intense pressure to expand and improve treatment and prevention programs, the armed services have hired additional mental health counselors, conducted advertising campaigns to encourage troops to seek care and instituted resiliency programs to help them control stress through diet, exercise, sleeping habits, meditation or counseling. Commanders are being instructed on how to identify the telltale signs of suicidal behavior as an early-warning system.
Yet the persistently high suicide rates have raised questions about which, if any, programs work. According to a 2010 report, the Department of Defense had nearly 900 suicide prevention activities, with multiple “inconsistencies, redundancies and gaps” in services.
Some experts say the Pentagon should focus on fewer programs that might have quicker impact. Some studies suggest, for instance, that simply improving sleeping habits can improve mental well-being. Others show that strengthening social connections, such as by having commanders or friends send “caring letters” to troubled service members, can prevent suicide.
But the stubborn nature of the problem is prompting more serious consideration of what suicide prevention experts call “means restriction,” particularly reducing access to privately owned firearms.
“If we want to limit suicide, we should put means restriction at the front because it works,” said Dr. Bryan of the University of Utah.
Indeed, the Pentagon is considering policies to encourage family members to take personal firearms away from suicidal service members. Commanders already have the authority to confiscate military-issue firearms from potentially suicidal service members.
But any such program is sure to be contentious and stir opposition from Second Amendment advocates. Dr. Woodson, the assistant secretary of defense for health affairs, said that the program would be voluntary, but that details were still being developed.
Perhaps the biggest challenge facing the Pentagon is simply getting suicidal service members into treatment. Surveys show that despite campaigns to reduce stigma, many service members continue to believe that treatment will be ineffective or hurt their careers, said Dr. Charles Hoge, a psychiatrist at Walter Reed National Military Medical Center.
“The problem isn’t the specific treatments, but the fact that individuals aren’t seeking care or are dropping out,” Dr. Hoge said. “There’s quite a bit of effort put into addressing stigma. But the fact remains that it is still a big problem.”
For that reason, the Pentagon’s first department-wide suicide prevention policy, to be released this year, will require “leaders to foster a command climate that encourages Department of Defense personnel to seek help,” Jacqueline Garrick, acting director of the Defense Suicide Prevention Office, told Congress in March.
Theresa Taylor wonders whether any of that would have saved her son, Specialist Hook, who seemed to fall through one crack after another.
His family had a long history of military service. But his mother, an Air Force veteran, encouraged him to enlist because he was a bright underachiever who used drugs. The military, she hoped, would help him grow up.
For two years, he seemed to thrive as a medic with the 82nd Airborne Division. But in 2010, his life veered wildly off track. He seemed deeply affected by suffering he witnessed during a humanitarian mission to Haiti early that year. Over the following months, there were tensions with his fiancée. An arrest for driving 160 miles an hour. A relapse into drug use.
When he visited his mother in Louisiana in October 2010, he seemed agitated, “not in a good place,” she said. He had begun taking antidepressants and seemed worried that his dream of joining the elite Army Rangers was becoming vanishingly distant. Adding to his stress, he was scheduled to deploy to Afghanistan the next March.
“He didn’t want to go,” Ms. Taylor said. “It didn’t have to do with the war or the Army. He felt like he needed to get his life straight.”
As Christmas approached, Ms. Taylor learned that he had asked his fiancée to enter into a suicide pact. She told his commanders at Fort Bragg, and they promised to put him on suicide watch.
But a mental health professional at the post decided that he was not suicidal and cleared him to go on holiday leave, Ms. Taylor said. Over the next day, he stabbed a drug dealer while trying to reclaim a Rolex watch, a cherished gift that he had traded for drugs, his mother said.
His sergeant, whom he told about the stabbing, took him to turn himself in. But on the way to the police station, Specialist Hook called his fiancée and said, “I’ll see you on the flip side.” Then he stepped from the car and shot himself using a pistol he had taken from a friend. He died on Christmas Day at the age of 20.
Ms. Taylor acknowledged that many of her son’s problems had predated enlistment. But she is haunted by a tape loop of questions about whether she, or her son’s friends, or his commanders, could have done more to help him.
“There is enough blame for everyone to go around,” she said. “The only reason you can blame anyone at all is that he was so young. If he was 40 and pulling these stunts, you’d say he should have learned. But he wasn’t.”
The New York Times: Experts concede they are not close to understand the root causes of why military suicides, which hit an all-time high in 2012, are rising so fast.
Experts concede they are not close to understand the root causes of why military suicides, which hit an all-time high in 2012, are rising so fast.
A former combat videographer describes trying to get her life back on track after her return from Iraq left her with PTSD and thoughts of suicide: http://nyti.ms/10ZSdig
Thursday, May 9, 2013
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—slated for release this month—has lost a major customer before even going to print. Thomas Insel, director of the National Institute of Mental Health (NIMH), declared last week on his blog that the institution will no longer use the manual to guide its research.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—slated for release this month—has lost a major customer before even going to print. Thomas Insel, director of the National Institute of Mental Health (NIMH), declared last week on his blog that the institution will no longer use the manual to guide its research. Instead, NIMH is working on a long-term plan to develop new diagnostic criteria and treatments based on genetic, physiologic, and cognitive data rather than symptoms alone.
Insel's pronouncement is the most recent hit in a long barrage of criticism that has rained down upon the latest DSM revision process since it began over a decade ago. "While DSM has been described as a 'Bible' for the field," he wrote, "it is, at best, a dictionary, creating a set of labels and defining each." Although the manual's strength has been to standardize these labels, he wrote, "[t]he weakness is its lack of validity," and "[p]atients with mental disorders deserve better."
Although Insel's blog was reported as a "bombshell," and "potentially seismic," NIMH's decision to scrap theDSM criteria has been public for several years, says Bruce Cuthbert, director of NIMH's Division of Adult Translational Research and Treatment Development. In 2010, the agency began to steer researchers away from the traditional categories of DSM by posting new guidance for grant proposals in five broad areas. Rather than grouping disorders such as schizophrenia and depression by symptom, the new categories focus on basic neural circuits and cognitive functions, such as those for reward, arousal, and attachment.
Live Chat: The Quest for Another Earth (Video) Thursday 3 p.m. EDT
Helena Kraemer, a biostatistician at Stanford University in Palo Alto, California, who was responsible for field trials of diagnostic categories proposed for DSM-5, says that Insel is right that the NIMH's new program, called Research Domain Criteria (RDoC) is "the direction we have to go." However, she says, "he's wrong in saying thatDSM-5 is to be set aside." When it comes to validity, there now is no gold standard, she says. "The DSM is a series of successive approximations." Kraemer's vision is that future versions of the manual will not have to wait 10 to 15 years for revision, but incorporate new scientific data from RDoC as it emerges. She says that a meeting is scheduled in June to discuss the possibility of converting the DSM into an electronic document that could incorporate those changes. "Everybody I've talked to about it thinks that's a good idea."
Frank Farley, a psychologist at Temple University in Philadelphia, Pennsylvania, and former president of the American Psychological Association (APA), isn't convinced that the whole process doesn't need to start from scratch, however. The measures of agreement between experts for several of the disorders in the new DSM-5were "terrible," he says. "What it suggests is that we need to go back to the drawing board." In 2011, Farley and colleagues circulated a petition for APA to submit the new revisions to independent review. Although 14,000 professionals and more than 50 organizations signed on, he says, "Nothing happened. We got a 'Thanks, but no thanks' letter back."
Both RDoC and DSM are necessary, says William Carpenter, a psychiatrist at the University of Maryland School of Medicine in Baltimore. Carpenter chairs the psychosis working group for the new DSM-5 manual and is one of three external advisers to RDoC. On a practical level, researchers and physicians need DSM to help characterize and treat patients in the field, he says. "If you don't, you just have 'Mental health I, II, III, IV and V.' "
On the other hand, Carpenter says, drug development for psychiatric disorders "has been stalemated for decades" due to our lack of understanding of the biological roots of psychiatric disease. "What I would hope for our field, is that clinically we get into the habit of deconstructing these syndromes into the specific pathologies that the patients have," such as hallucinations and impaired emotional processing. Once we understand the neural circuitry and neurobiology that cause such symptoms, he adds, "hopefully this will help drag drug companies into trying to make novel discoveries, instead of me-too drugs that they've lived off of for all these years."
Implementing RDoC will present some practical challenges, Carpenter acknowledges. "This does shift the paradigm." Rather than excluding all study subjects who do not fit a DSM diagnosis, such as major depression, for example, the new approach might include a range of participants with different diagnoses who all demonstrate anhedonia, the impaired ability to experience pleasure, and might look for underlying brain abnormalities that they share in common. "I bet that the rough spots are overcome pretty quickly," Carpenter says, "but of course we have to see how well that actually works out."
Cuthbert emphasizes that the new system is a framework for research, not a diagnostic manual, and that it has not yet been tested. "It's a platform to get people moving in the right direction," he says. In the meantime, theDSM "has been and continues to be very useful in psychiatry," he says. For the sake of patients, he says, "it's important to communicate that we do have good treatments for mental disorders."
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May 6, 2013
Psychiatry’s Guide Is Out of Touch With Science, Experts Say
By PAM BELLUCK and BENEDICT CAREY
Just weeks before the long-awaited publication of a new edition of the so-called bible of mental disorders, the federal government’s most prominent psychiatric expert has said the book suffers from a scientific “lack of validity.”
The expert, Dr. Thomas R. Insel, director of the National Institute of Mental Health, said in an interview Monday that his goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.
While the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., is the best tool now available for clinicians treating patients and should not be tossed out, he said, it does not reflect the complexity of many disorders, and its way of categorizing mental illnesses should not guide research.
“As long as the research community takes the D.S.M. to be a bible, we’ll never make progress,” Dr. Insel said, adding, “People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”
The revision, known as the D.S.M.-5, is the first major reissue since 1994. It has stirred unprecedented questioning from the public, patient groups and, most fundamentally, senior figures in psychiatry who have challenged not only decisions about specific diagnoses but the scientific basis of the entire enterprise. Basic research into the biology of mental disorders and treatment has stalled, they say, confounded by the labyrinth of the brain.
Decades of spending on neuroscience have taught scientists mostly what they do not know, undermining some of their most elemental assumptions. Genetic glitches that appear to increase the risk of schizophrenia in one person may predispose others to autism-like symptoms, or bipolar disorder. The mechanisms of the field’s most commonly used drugs — antidepressants like Prozac, and antipsychosis medications like Zyprexa — have revealed nothing about the causes of those disorders. And major drugmakers have scaled back psychiatric drug development, having virtually no new biological “targets” to shoot for.
Dr. Insel is one of a growing number of scientists who think that the field needs an entirely new paradigm for understanding mental disorders, though neither he nor anyone else knows exactly what it will look like.
Even the chairman of the task force making revisions to the D.S.M., Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh, said the new manual was faced with doing the best it could with the scientific evidence available.
“The problem that we’ve had in dealing with the data that we’ve had over the five to 10 years since we began the revision process of D.S.M.-5 is a failure of our neuroscience and biology to give us the level of diagnostic criteria, a level of sensitivity and specificity that we would be able to introduce into the diagnostic manual,” Dr. Kupfer said.
The creators of the D.S.M. in the 1960s and ’70s “were real heroes at the time,” said Dr. Steven E. Hyman, a psychiatrist and neuroscientist at the Broad Institute and a former director at the National Institute of Mental Health. “They chose a model in which all psychiatric illnesses were represented as categories discontinuous with ‘normal.’ But this is totally wrong in a way they couldn’t have imagined. So in fact what they produced was an absolute scientific nightmare. Many people who get one diagnosis get five diagnoses, but they don’t have five diseases — they have one underlying condition.”
Dr. Hyman, Dr. Insel and other experts said they hoped that the science of psychiatry would follow the direction of cancer research, which is moving from classifying tumors by where they occur in the body to characterizing them by their genetic and molecular signatures.
About two years ago, to spur a move in that direction, Dr. Insel started a federal project called Research Domain Criteria, or RDoC, which he highlighted in a blog post last week. Dr. Insel said in the blog that the National Institute of Mental Health would be “reorienting its research away from D.S.M. categories” because “patients with mental disorders deserve better.” His commentary has created ripples throughout the mental health community.
Dr. Insel said in the interview that his motivation was not to disparage the D.S.M. as a clinical tool, but to encourage researchers and especially outside reviewers who screen proposals for financing from his agency to disregard its categories and investigate the biological underpinnings of disorders instead. He said he had heard from scientists whose proposals to study processes common to depression, schizophrenia and psychosis were rejected by grant reviewers because they cut across D.S.M. disease categories.
“They didn’t get it,” Dr. Insel said of the reviewers. “What we’re trying to do with RDoC is say actually this is a fresh way to think about it.” He added that he hoped researchers would also participate in projects funded through the Obama administration’s new brain initiative.
Dr. Michael First, a psychiatry professor at Columbia who edited the last edition of the manual, said, “RDoC is clearly the way of the future,” although it would take years to get results that could apply to patients. In the meantime, he said, “RDoC can’t do what the D.S.M. does. The D.S.M. is what clinicians use. Patients will always come into offices with symptoms.”
For at least a decade, Dr. First and others said, patients will continue to be diagnosed with D.S.M. categories as a guide, and insurance companies will reimburse with such diagnoses in mind.
Dr. Jeffrey Lieberman, the chairman of the psychiatry department at Columbia and president-elect of the American Psychiatric Association, which publishes the D.S.M., said that the new edition’s refinements were “based on research in the last 20 years that will improve the utility of this guide for practitioners, and improve, however incrementally, the care patients receive.”
He added: “The last thing we want to do is be defensive or apologetic about the state of our field. But at the same time, we’re not satisfied with it either. There’s nothing we’d like better than to have more scientific progress.”
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The DSM-5 and Forensic Psychiatry. - Wortzel HS