Monday, September 15, 2008

In Practice: Of Human Frailty

By Peter D. Kramer in In Practice

Early in my career, when I served as head of ambulatory psychiatry for a group of hospitals here in Providence, Rhode Island, I happened to take a trip to Israel. In Jerusalem, I found myself explaining my job to a skeptical audience. What were outpatient services? a woman wanted to know. Who needed them?

Searching for a case that would put me on solid ground, I began to tell the story of a young man injured in an industrial accident. Nerves serving his arm had been avulsed, that is, they had been tugged in way that made the arm useless and painful. The man had become depressed and had not returned to work . . . and here the woman interrupted me. Why had he become depressed?

I could see her point. We were in a country where young men and women went to war and lost limbs all the time, a country whose citizens remembered an era where Jews suffered more grievous injury, so that mere loss of limb might be deemed a small thing.

Some people who turned to our clinics did become depressed, I told the woman, when they could no longer function as they once had, when they considered themselves less attractive, less useful, and less whole than they once had been.

My challenger nodded in understanding, although an understanding was not what we had come to. I suspect she thought that Americans were constitutionally weak or that I must be dealing with a subpopulation whose members were emotionally fragile and so might need help after all. I was certain that she did not share my opening premise, that a sudden injury might be an obvious trigger for a marked change in mood and overall wellbeing.

I thought of this encounter when I came across an article in the current Annals of Surgery. Douglas Zatzick, a psychiatrist at the University of Washington, and other researchers analyzed data on thousands of patients in dozens of American hospitals and trauma centers. Looking at men and women who arrived at the facilities with a traumatic injury and survived a year, the researchers found a PTSD rate of 20.7% and, independently, a depression rate of 6.6%. Patients with one mental illness were three times as likely to be out of work; two diagnoses made a return to work five or six times less likely.

Might these figures look different in a different culture? Perhaps, but frailty is a condition of our existence; our beliefs about our toughness tend to draw on myth more than objective truth.

I was once on television by remote with the news anchor Brian Williams, and he strayed from the topic at hand to ask about post-traumatic stress disorder. Why, Williams wanted to know, was there so much less of it in World War II, with what his colleague Tom Brokaw had called “The Greatest Generation?”

The question caught me off guard, but I replied that there had, I believed, been high levels of “war neurosis,” and that the subsequent community mental health movement had been shaped by military doctors’ responses to that disorder in the War. Later that week, I sent Williams data on the problem, but only recently have I come across a compact, forceful overview of the extent of the problem.

Allan Horwitz and Jerome Wakefield, in The Loss of Sadness (a book I have criticized on other grounds), write that in the Second World War nearly a million American soldiers suffered “neuropsychiatric breakdowns.” In combat divisions, a quarter of soldiers were hospitalized for psychiatric reasons, and the figure soared to 70 per cent among those exposed to long stretches on the front lines. According to a contemporary estimate, the average soldier would suffer a breakdown after 88 days of continuous combat; by 260 days, the psychiatric casualty rate reached 95 per cent.

It would be interesting to read studies of responses to trauma in other countries. But I suspect that American workers, like American soldiers of the Greatest Generation, are reasonably sturdy. The problem is that as humans, we’re just not made to withstand very high levels of stress, whether chronic and relentless or acute and intense.

Note of coming events: The press reports today on research showing that the new antipsychotic medications are no more (and perhaps less) effective than older medicines in treating psychosis in children. For unknown reasons, the American Journal of Psychiatry has not yet uploaded the research paper onto its Web site. I hope to comment on this issue once I have had a chance to see the underlying study.

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