A Dangerous Method

A new movie titled A Dangerous Method is reviewed. It is about Carl Gustav Jung played by Michael Fassbender. It also includes Sigmund Freud played by Viggo Mortensen and Sabina Spielrein , one of Jung’s patients, played by Keira Knightley.

A recently released movie is all about Carl Gustav Jung, his life, his theories and his various interactions including one with Sigmund Freud. It  as titled A Dangerous Method. I wrote a review of this film in a movie blog that I write with my wife titled FilmRap.net.

It is reproduced below. As always your comments are invited. In two weeks my next blog will feature an interview about this movie with Dr. Thomas Kirsch a Jungian analyst.

A Dangerous Method

As people who have some some acquaintance with  psychoanalytic theory and it’s history, we were drawn to want to see this movie. The psychiatrist among the two of us found it a more enjoyable experience although we both found many deficiencies in the movie. This movie, directed by David Cronenberg, with a screenplay by Christopher Hampton which came from a book by John Kerr, of course is based on real people and highlights the break between Sigmund Freud and Carl Gustav Jung who at one time Freud had thought would be his heir apparent to the psychoanalytic movement. The movie starts off in the early 1900s as a young women, Sabina Spielrein (Keira Knightley) is involuntarily brought to the Burgholzi, a  psychiatric hospital in Zurich, Switzerland, run by the famed Eugen Bleuler. Her exaggerated mannerisms and dramatic presentation suggests the type of “hysterical” patients who were known to be hospitalized in those days. Jung (Michael Fassbender) becomes her psychiatrist at the hospital and begins to use the new psychoanalytic method which Sigmund Freud (Viggo Mortensen) in Vienna has advocated. He ultimately is shown  becoming drawn into a sadomachistic sexual romantic affair with her. Jung travels to Vienna and meets with Freud several times in which they discuss theoretical issues as well as this patient. Over time Freud is depicted as becoming disenchanted with his previously highly regarded younger colleague. The reasons for this rift would appear to be Jung’s willingness to go beyond Freud’s concept of sexuality and psychic determinism and bring in such ideas as the supernatural, premonitions, telepathy, religion and many others that were not explained in much detail in the movie. In fact, the more well known ideas of Jung about the collective unconscious , symbolism and dream analysis were not very well clarified.

Carl Gustav Jung

Freud appeared to be concerned that any significant deviation from his main thesis and what he believed was the scientific method might be a reason for his theories to fail to gain wide acceptance. As best we can determine, in reality the actual affair between Jung and Speilrein was suspected, but historically it was  not universally agreed that it had actually occurred. In this movie it is shown that  Speilrein wrote to Freud and told him of her affair after Jung rejected her. Freud did not believe her and she subsequently is depicted as convincing Jung to acknowledge the affair to Freud who then gave this as an additional reason for cutting his ties with Jung. Once again Freud is very concerned about the appearance of his analytic movement and such behavior as an affair with one’s patient  at that time as well as at present would be highly unethical. The nature of the affair and the meaning of their attraction to each other is really a key part of this movie, whether it actually happened or not. The characters in their dialogue state that Jung, who is shown being torn by the relationship, views attraction to his patient to be  on the “dark side” and that with his wife on the “loving” side.  Yet he declares his undying  love for Spelrein and is bereft by her leaving him. We are not provided with real insight inot this relationship nor any significant understanding of Jung’s conflict. The film also does not do enough to explicate Jung’s ideas and their influence on Spielrein. While we more often proclaim that a movie should have been tightened up and shortened we believe this film needed a clearer illustration of the ideas that this story was supposed to be  about.  The acting in the film was very strong. The atmosphere of Freud’s office, the streets , people’s dress, horse drawn vehicles and early motor cars made it a wonderful period piece. But alas, as much as we were interested to learn about these people, we felt we came up short in our understanding as well as in caring about them.

Coming Soon : Q & A  About This Movie with Dr. Thomas Kirsch

The next PsychiatryTalk blog will feature a  special interview with  Dr. Thomas Kirsch, a psychoanalyst  and leading expert on Dr. Jung. In it Dr. Kirsch will discuss how well it depicted the various people in the movie as well as Jung’s theories.

How We Survived- 52 Holocaust Child Survivors

This is a book of 52 personal stories by child survivors of the Holocaust

How We Survived– 52 Personal Stories by Child Survivors of the Holocaust

I have read many books about the holocaust, have seen many movies about this subject and have visited various holocaust museums throughout the world.  As a psychiatrist, I have treated a few holocaust survivors and many more children of holocaust survivors. I was therefore surprised how impacted I was by reading this book which consisted  first person stories of 52 holocaust survivors most of whom were born between 1926 and 1938.

I became aware of this book  when a good friend of mine John Glass who is one of the 52 authors, showed me a copy of the book and told me about the project behind it. Each author is a member of the Child Survivors of the Holocaust, Los Angeles Organization that was founded in 1983.  Dr. Sarah Moskovitz and Dr. Florabel Kinsler organized the largest international group of child survivors with a membership of more than five hundred people. In the introduction to this book, Marie Kaufman President of the Los Angeles child survivors group and Chair of the Editorial Committee that put together the book noted that many of the authors have given oral testimony  to museums  and to the Shoah Visual History Foundation. But in the fifteen to twenty years since they have done so, they have become aware that for many reasons they have left part of their story untold. This book gave them opportunity to disclose secrets never divulged before.

As one reads this book and digest the  narrative which is recounting horrific early childhood memories, you cannot help but consider whether these are true memories. Could they be screen memories, retrospective memories based on things they were told and learned at a later age? In the course of psychotherapy and psychoanalysis we  often help patients reconstruct early childhood memories and feelings. The accuracy of the actual memory may not be as important as the meaning. I do believe that the memories reported in this book do ring to be quite true. I also would suggest a simple exercise before you read this book. Reflect back on your three or four earliest memories. Sometimes it will be helpful to choose a key event which you can easily date such as the birth of a  sibling, a  death or tragedy or famous event such as the assassination of JFK or Martin Luther King or the  landing on the moon, a particular grade school teacher etc. Often the event that you recall will have some negative or conflictual quality. My own earliest memory is when my mother left me alone  in our apartment for a few minutes to do an errand and brought me back a chocolate bar. When I discussed this memory with her many years later, she was astounded that I exactly recalled the events and she was able to date it when I was less that three years old. I recalled being under the care of an aunt during the time that my sister was born and my disappointment that a cousin has seen her first. I was less than 5 years old .   I also recalled my first day of kindergarden , when I was a  few months older than 5. While each of these memories had some anxiety and conflict, they were minuscule compared to the intensity of experiences of being taken away from one’s parents, hiding for prolonged periods of time, starving and witnessing and being threatened with death and destruction, all of which were common place in the 53 stories of this book.

There is another important dynamic which inhibited many of the child survivors from publicly telling their story . Many were hidden children who often had to assume non Jewish identities, sometimes having  several different gentile names and personas over time,  as young children during the war . Each time it was impressed upon them that under no circumstances were they to reveal their Jewish identity as this could mean death to them and their adopted families. So even after they were liberated, reunited with any surviving families and were beginning new lives in the United States, many still would not readily talk about their Jewish identity especially with strangers

It is very difficult to understand the experience that these children had where a  normal childhood was transformed almost overnight when Kristalnacht occurred in Germany, or when the Germans took over in Poland and issued the new regulations for Jews or similar events that happened in France, Hungry, Italy, Holland  and any other places conquered by the Nazi’s. They moved from their comfortable apartments or homes to the Ghetto where they were jammed into one room with extended families and strangers. In anticipation of this situation or in response to it many of their parents who suspected even worst was to come  made a decision  to send their children into hiding with non-Jewish families. In most of the cases the parents could not be hidden with their children. Childhood separation from parents is a very meaningful experience, usually traumatic with the possibility of lasting yearning, resentment, with a wide range of fantasies. This becomes colored by the subsequent events which might include loving or rejecting the adoptive parental figures  as well as being torn away from one such family as you are moved to another one.  The fate of their own Jewish  parents was often death as was that of most of the their original  families and friends. While many of the  child survivors intellectually came to understand that the decision to try to hide them allowed them to live, the full emotional understanding of this generous act on the part of their parents did  not come to them until many years later. It was often when their own children born in a safe environment were now the age at which they had been  put into hiding by their own parents, did they appreciate the sacrifice that was made for them. For some this realization did not occur until they had grandchildren who are at the age that they were hidden .

It is important to note that the trials and tribulations for many of these child survivors did not cease with their liberation from concentration camps or from their places of hiding.In some situations there was persecution by the Russians who liberated them or continued anti-Semitism when they tried to return to their home town. There were hard times often relieved by the many  organizations and people who tried to help them reunite with any exisiting  families. There were painful discoveries of what happened to missing family members. There was also  long waits for visas to new countries , travels across the ocean, learning new languages and adapting to a new culture

As was the case of many survivors who were adults during the holocaust, these child survivors  spent many years trying to forget and not to look back.  Their parents who survived or adoptive parents and relatives often did not believe that the experiences which they had as children made a lasting impression on them. They were building a new a life and did not want their own children haunted by such terrible events. As they moved on to a “normal life” in the United States the child survivors themselves thought that their memories and experiences were quite unique and as mentioned above were not inclined to talk about them. Many report an amazingly dramatic unburdening feeling when they attended their first meeting of child survivors. The intensity of that feeling and the realization that so many other children had gone through similar events was life affirming and literally changed the course of the lives.

It is noteworthy that so many of the child survivors have gone on to have very productive lives. Perhaps because they themselves have been helped by strangers (many of whom have been recognized in Yad Vashem  as the ‘righteous gentiles”  or “righteous among nations”) they have chosen a helping profession themselves. It seems to me that a high percentage have gone on to be social workers, therapists  and teachers. Some report moving into these fields after a successful career in business. Others have become artists and poets expressing their feelings and experiences in their work. There were numerous poems  as part of the narratives.

Many of the child survivors did not talk about the past for most of their lives   and for many it has only been in their twilight years that most have  felt an obligation to tell their stories or record  a first hand account that will exist for future generations. A good number of the authors of this book   have devoted many hours to teaching about the holocaust in schools and museum  and giving lectures in various settings. These activities and the writing of the chapter for this book as well as other publications that some of them have done appears to have been therapeutic for them.

The authors  tried their best to be sincere and honest in sharing all these events and their past and present feelings about what they have been through. For  most there is a triumph for having survived and for being responsible for the presence of so many wonderful people that they have nurtured and supported in their subsequent  lives  For some of people there is still an ever present wound or bewilderment and pain which stretches from their childhood to their later years. They are still trying to figure out why and how the events of their childhood  could have happened. For all there is the satisfaction of having told the story of what really happened  so those who were deprived of their lives will not be forgotten 

This was not an easy book to read. While I read it in linear fashion over a two week period and did not intersperse with other books perhaps that might not be the best way to read it. For some it might be best to consume it in small doses .  I suspect that some readers will appreciate the value of the book but will put it aside and may not complete it.

I realize also that I may not have captured the essence of the experience of the authors in this review. I would like to give you a few random excerpts although I hope over time you will read the complete version of each of these  52 stories as they all deserve to be remembered:

Lea- Born 1938 I was placed through the Dutch underground with a Christian family. There were many other children. Suddenly the family was betrayed. The underground took all the children away to new hiding places. On of my first memories was of being on a train with other boys and girls…. I  was taken to family of farmers in the small town of Horst by two men dressed in police uniforms. My clothes were torn and I had sores all over my body.  The men said that they ha d smuggled me out of some detention center but I have never been able to find out what happened to me.

Jack- Born 1926- The ghetto was organized  into factories of every possible trade and all the  the production was for the German military…My father could not get employment…When I saw my dad for the last time he was forty one years old…In July 1944 we were transported in cattle cars to Auschwitz-Birkenau. I was with my mother…(We) went through a selection conducted by Dr. Mengele. My mother was sent to the other side. Now sixty four years later, I can still see her walking hunched over, as if she know where she was going. I’m still haunted by this picute and I know that I will for the rest of my life. How do I reconcile the fact that my children are now older than my parents were when they were murdered.?

Lya- Born 1936- When I was seven and she (sister) was four we both went into hiding with different families. The thought never occurred to me that this would be the last time I’d ever see my parents. They never knew where we ended up…In 1946 my sister and I were sent live with  Parents Number 5 in Denmark…I was a very difficult teenager. Obstinate, opinionated, aggressive. I was sent out of class many times. It was sheer anger- a way of expressing myself to the world…My husband ( also a survivor) wasn’t interested in talking about his experiences and for the longest time I didn’t think that mine really countered. …I started dealing with my past in 1993, I was fifty six…. That’s when I first shared my story ( in a group ) about  losing my parents, grandparents, being separated from my sister and being in hiding with strangers. After that night, I became more aware of my own feelings. I could justify them. They were real and they weren’t something nonexistent.

Peter- Born 1936- In 1940 when I was four years old I was no longer permitted to attend my pre-school nor to attend any other school. From my earliest memories, I had to wear a yellow star with the word “Jude” on my jackets and shirts…People looked at us in disgust and were often rude to my mother when she shopped for food…Only 32 out of the 100 Jews transported in the cattle car I was in survived the Holocaust. I lived in the children’s barracks (in Terezin)…We slept in bunk beds on straw and had only a thin blanket. There was only cold water to wash ourselves in the summer and harsh winters…There was small piece of bread in the morning with some brown water they called “coffee” and for supper a watery soup with  an occasional small potato. We were half starved yet we were expected to work…(After the war)I lived my teenage years as a laborer, farm hand truck driver across the US. …By the age of 33 I had completed high school, graduated from San Diego State University and received a graduate degree in  Global Management.   … I have seven grandchildren.

Robert- Born 1935- When I was four years old our lives changed forever, The Gestapo came to our apartment and told us to take just a little luggage and follow them. They sent us by train to the Polish border. The poles would not let us in and Germans would not take us back…We traveled around Poland living as gentiles with an assumed name….The family that hid me decided to put me in the attic in the house. Many times they forgot to take care of me and did not feed me. …After the uprising failed the Germans planned eliminate the city’s population.. Everyone was loaded upon trains, which were headed to Auschwitz. …We knew we were going to be killed…My mother noticed that one of the cars had an opening on top. The train stopped about 100 yards from the Auschwitz concentration camp. My step father Emil lifted me up over the open car and I was able to open the train car door…In February 1947 we took a boat to America and settled with our extended family in Pittsburgh. I quickly learned English and graduated from Carnegie Mellon University in 1957 with degree in electrical engineering. …Over the years I have spoken about the holocaust to thousands of middle and high school children.

Erika- Born 1928- At the time of my birth my parents (in Hungary) owned two kosher restaurants.  I went to school unitl the age of fourteen when the anti Jewish Hungarian government closed the Jewish schools. Anti-Semetism forced many Jewish owned businesses to close or be taken over by non-Jews. Most of my uncles had been taken to forced labor camps in early 1940-42…I was deported to Auschwitz with my mother. We were lucky and escaped the selection. …On the day the Soviet liberators entered our camp they raped many women and wanted us to work for them. …I was helped tremendously by breaking the silence and talking about my experiences. Confronting my losses and acknowledging the effects of the traumatic times in my life have helped me to recover psychologically. However I still have problems such as fear of authority, anxiety about the health of my family, about separation  and the fear of loss.

For more information or to order this book go to www.childsurvivorsla.org

Telepsychiatry Today and Tomorrow

Three examples are discussed where he author has become involved in the delivery of psychiatric treatment via telepsychiatry (video conferencing). The first is in a county rural mental health clinic in California. The second is in conjunction with the Chinese American Psychoanalytic Alliance (CAPA) where mental health professionals in China who are in a training program provided by American teachers via SKYPE ( video conferencing) desire to have their own personal one to one psychotherapy by this technique. The third is psychotherapy in the United States for private patients who for a variety of reasons find it more convenient and feasible to have their therapy via telepsychiatry.

A county rural mental health clinic in California is set up to provide  psychiatric  services to the surrounding area but there aren’t enough psychiatrists in the area who are able to travel to staff this clinic morning and afternoons five days per week.

An  American  training program for mental health professionals in China provides classes via telepsychiatry (via video conferencing ) but many of the trainees wish to have their own therapy by experienced therapists who are in quite short supply in China at this time.

There are highly functioning productive people in the United states who are in occupations and jobs which often take them out of town or have long commutes to work with irregular work hours. This situation makes it quite difficult for them to arrange  psychotherapy with experienced psychiatrists  which would require them to come for sessions at least once per week.

During the past year I have become involved with devoting part of my practice to telepsychiatry and am now offering therapy in each of these three situations.

When I agreed to provide treatment one morning per week to the above mentioned clinic I already had experience in teaching courses online with video conferencing but I had not treated patients with this modality. I knew that some of these patients might have complicated mental illnesses which would require complex medications and that some might have to be hospitalized. I was aware that certain paranoid patients could be suspicious of electronic communications and some patients might require a translator if they did not speak English. I was pleasantly surprised to find how smoothly everything was able to run. A mental health nurse is in the room with the patient and a translator was available when needed.  The patients understood the concept that they were being seen by a psychiatrist in another city via video communications. We had a clear face to face discussion and the patients seemed as comfortable as in any other setting in bringing me up to date on their symptoms. I had access to a very sophisticated confidential electronic medical  record where I could record my findings and check the observations of any other visits that the patient had at this clinic. I could refer the patient for lab tests as well as to a primary care physician. I also could make referrals to other mental health professionals connected to this clinic who could do individual, family  or group meetings  with the patient. I prescribed medication directly through a very efficient electronic prescribing system, which electronically connects to every pharmacy in the state. If needed I could alternately fax a prescription or make a telephone call directly to the pharmacy. On the few occasions where a patient needed an immediate hospitalization I could arrange that and provide the referral information needed by the admitting doctors. It has been a very gratifying experience to spend this time providing this needed service.

First CAPA Graduation in Beijingi

For the past year I had been teaching as part of  the Chinese American Psychoanalytic Alliance (CAPA),a very innovative program  founded by a friend and colleague Dr. Elise Snyder.This program uses video conferencing mostly by Americans who provides high quality training to mental health professionals in China who previously had very limited access to this type of training. The program has grown and become quite in demand by young Chinese professionals embarking  upon a career in providing mental health treatment in China. One year ago I participated in study tour to China with CAPA where I had an opportunity to give a few lectures and also witness the first graduation from this program which was held in Beijing. In conjunction with such training, it has been common for the trainees to arrange their own personal therapy. Unfortunately for a variety of reasons, there has been a lack of therapists  who could offer such treatment to the trainees in China. Many of the Americans who have been teaching in this program have offered to treat such a Chinese trainee via telepsychiatry ( video conferencing) as did I. Due to the wide disparity in income between Americans and most Chinese, such treatment has to be offered at fraction of the usual fee received by American therapists in the United States. The trainees usually speak English quite well but there are at times interesting challenges related to the nuances of the meaning of words as well as in understanding various cultural differences. The fact of there being a “ one child policy”  in China means most of the trainees have grown up as an only child which has important psychological significance. Most Americans are not familiar with the Chinese concept of “shame” which reassembles but is quite different than “depression” which can be an important part of the childhood experience of growing up in China. Participating in this program as a therapist has also been a gratifying and interesting experience which I am pleased to continue.

The third situation which I described above, reflects an anticipated  shift in the  attitudes of many Americans towards  technology and psychotherapy. This change, I believe, is taking place in both patients and therapists. I practiced psychiatry in Manhattan as well as in a suburb of New York City  and more recently now in Los Angeles. I have seen  many sophisticated patients who chose their psychiatrists by referrals from trusted physicians or friends and would rework their schedules to make regular sessions, often in the early morning or evenings. People tended not to change jobs very often and it was common to have an entire course of  therapy with one therapist. Now days people commonly choose their psychiatrists after a careful investigation of their credentials and background online. Since the Internet is used for obtaining other important information it seems natural for  so many people to rely on the Internet and feel comfortable in evaluating information available on it. It is a known fact that people are changing jobs much more frequently, even in  higher paying positions. Therefore, one can’t be confident that a therapist in one location will be convenient to see at a later date. It seems that time is even at a greater premium than it was in the past. Commuting time is longer especially in a city such as Los Angeles and work environments frequently require people to be quite flexible. This means working at home at times, traveling when needed and irregular hours. Certain occupations such as the entertainment industry in Los Angeles requires long periods of time out of town as does pilots and airline personnel to name just a few. There is  increasing comfort with modern technology illustrated by  the growth of the use of video conferencing in business and education and the personal use of texting, Skyping , Facetime etc. Therefore it is inevitable that there will be a shift in the practice of medicine to use more telemedicine and for psychiatrists to use increasing amounts of telepsychiatry.  Therefore, I was very interested when the California Telepsychiatry Group (also now American Telepsychiatry) ,who were running the services for the mental health clinic described above, asked me if I would be interested in devoting some time to seeing private patients with their group.

I spent some time talking with their Director Dr. John Schaffer and I was impressed how they have arrange their video conferencing, electronic records and electronic prescribing to be HIPPA compliant (meaning state of the art confidentiality techniques) . They had addressed the various legal, ethical and questions of malpractice insurance and were carefully vetting the psychiatrists who would work with them. In addition they set up a very novel and interesting “meet and greet system” where potential patients, at no cost, could have a preliminary 10-15 minute   telepsychiatry meeting with any of the psychiatrists available for treatment . They could therefore review the credentials and experience of potential therapists, as well as meeting them, before they decided to enter into treatment. I am very pleased to now to be connected to an entity which I believe is on the cutting edge of a system for providing quality psychotherapy with this modality.

I suspect in 10 years from now or less,  people will look back on the three examples which I described above and see them all as every day occurrences in the delivery of mental health services in this country and throughout the world.

My Experience During 9/11

At the time of the commemoration of the 10th anniversary of 9/11 I reflected on my experiences at that time. The phenomena of “missing persons” posters which appeared throughout Manhattan shortly after the tragic events is discussed as well as some other observations about this fateful event.

Several weeks ago we commemorated the 10th anniversary of 911 and like many of you. I reflected back on what I was doing and how that event impacted on our lives. The latter question will require much more continued contemplation. However, the memories of that day and subsequent weeks were quite meaningful.

I lived in the northern suburbs of New York City at the time and the local newspapers had photographs of cars in train station parking lots that were not picked up by commuters who had perished in the World Center attack. I did not think that I knew anyone personally who died or had a close family who was killed  in the tragedy. Several months later I found out that  a chaplain with whom I worked with from time to time at the medical center had lost his son who worked at the World Trade Center. Over the ensuing years I saw many patients whose lives were impacted significantly by this event and worked in intensive therapy with several of them.

On the morning of 9/11/01 I was at Westchester Medical Center when I heard of the unfolding events. The nearest television set was on a psychiatric inpatient service near my office. I sat with staff and patients and watched the second plane hit the tower. Although many of the patients had severe acute mental illness-schizophrenia, other psychosis, suicidal behavior etc., we all responded in the same manner. There were groans and tears and statements of  “those poor people.” There was no panic and no apparent incorporation of this reality into the patient’s delusions. It has been shown that people with decompensated mental illness often show improvement at least in their short term symptoms when they are faced with emergency or tragic events.

I was reminded of an experience I had while I was in training in New York City many years previously when there was a sudden unexpected blackout with loss of power citywide for at least several hours. I also was visiting on a psychiatric inpatient service when it occurred and most people handled it quite well. I eventually published a paper how this event did interact with the psychopathology of a two patients.

By coincidence I was scheduled to give a Grand Rounds presentation on September 21 , 10 days after 9/11 at a hospital in downtown Manhattan from which you would have been able to see the World Trade Center. Ironically the topic of my talk had been about disaster psychiatry but I changed it to specifically allow a discussion on how my colleagues had responded and what they had done to address the mental health issues related to this tragedy in their backyard. A center had been set up on Pier 92 for the survivors, families and friends  of the victims. Mental health professionals from all over the Metropolitan area donated their services to work with the Red Cross in helping these people with their physical and emotional needs.

At the time of this presentation, I walked around downtown Manhattan and the area surrounding ground zero. I noted the presence of something very interesting there and also scattered throughout Manhattan.. There were posters with pictures made by family and friends of people who had been in the World Trade Center at the time of the tragic events and did not come home. The posters, as you can see, were made from the point of view that these people were “missing.” They provided a description of the person with the request that if anybody were to see them they should call a specific telephone number. There were numerous such posters. The fact is that people were not found wondering throughout the city. The relatively few injured people who were brought to the hospital were identified and families were notified. Of course, the New York City morgue had a very sophisticated system of trying to contact any family members if they had made identification of the remains of victims. So what were these posters about?

They obviously were part of the denial phase of  the acute complicated grief that the survivors were beginning to feel as on some level they realized their  loved ones were killed. Within the next two weeks people began to make alterations in these posters which showed that they recognized that these people had died.  They crossed out the words “lost” or  “missing” and would write things like “in memory of”. The posters now would be adorned with flowers. I don’t recall this phenomena ever being reported in the psychiatric literature.

While I did not participate in the work on Pier 92, I was asked to do some “debriefing” activities for some organizations. One such group was the personnel of a major TV network. (I had done some previous work identifying the psychological trauma that members of the working press often experience in the course of their work). I was the co-leader of this group with a Professor from the Columbia School of Journalism.  Prior to this time debriefing activities would have meant trying to get the participants to express their emotional reactions to their recent experience in the disaster. More recent research had suggested that this wasn’t the best approach. In fact,  it might even make things worst. So our approach was a much more general approach in which we acknowledged the type of emotional symptoms that they might experience and made suggestions how to minimize them.

The evening before I worked with this group I had spoken with a family member of mine who told me that she had a dream that the well known television anchor from this network was having a personal conversation with her about the disaster. This dream appeared to reflect the importance that such TV personalities have in reassuring people at the time of frightening events. I was able to tell my relative that I spoke with the TV producer who worked with this anchor and she was going to tell him about her dream .

There has been a great deal written about this disaster in professional journals as well as in other media.We also will dearly hold on to our personal memories of that fateful day. Feel free to relate any of your experiences or thoughts about this day in the comment section below.

The Connection Between Depression and Stroke

A recent article published in JAMA has concluded that depression is associated with a significantly increased risk of stroke morbidity and mortality.
This important topic is further discussed.

A recent study published in the  Journal of the American Medical Association  concluded that depression is associated  with a significantly increased risk of stroke morbidity and mortality. This means that if you have depression you are more likely to have a stroke and die from a stroke as compared to a situation where you didn’t have depression .

This is quite relevant to a large number of people since depression is quite prevalent in the general population. It is estimated that 5.8% of men and 9.5% of women will experience a depression e episode in a 12 month period. The lifetime incidence of depression has been estimated at more than 16% in the general population.

This research study was by Dr. An Pan  and four colleagues from the Harvard School of Public Health and Harvard Medical School. The research was a meta-analysis and a systematic review which meant that the authors studied research of many studies on this subject The ended up looking at 28 prospective cohort studies comprising 317,540 participants which reported 8478 stroke cases during a follow-up period ranging from 2-29 years.

Their scientific analysis of the data demonstrated that depression is associated with a significantly increased risk of developing stroke. They also found a positive association of depression with a fatal stroke.

The authors discussed a variety of mechanisms which depression may contribute to stroke. Depression has known neuroendocrine effects. For example t there is a dysregulation of HPA axis ( hypothalamic-pituitary-adrencortical axis which can cause high blood pressure. It has been shown that depression effects platelets and leads to  dysfunction which causes abnormalities in the clotting mechanism. There are also abnormalities in the immune and inflammation systems which could influence stroke risk..

Depression is associated with poor health behaviors such as smoking, physical inactivity, poor diet, lack of medication compliance and obesity, all of which may contribute to stroke.

Depression has already been associated with coronary heart disease, diabetes and hypertension. (See an earlier blog on depression and heart disease as well as another blog which raised the question whether people with depression should be taking aspirin to prevent heart attacks).

The data from the recent JAMA study also suggested that it is possible that antidepressant medication may be associated with stroke risk but this may be a false impression since medication use can be a marker of depression severity and many of the studies that the authors looked at lacked information on dose and duration of medication use.

There are some limitations of this study and the findings don’t prove 100% that depression causes stroke. I would imagine that it is conceivable that the genetic markers for stroke and depression could be located in close proximity leading to such impression of this effect. However even if there is no causative effect (  although I believe the research strongly suggest one ), the association of these conditions clearly calls out for great attention being paid to this association. There is an opportunity for doctors who see patients who are at a high risk for stroke to be referred for treatment of depression. Also patients who are being treated for depression should be encouraged to be seek medical attention and assistance in reducing all the other risk factors for stroke whenever possible.

Depression is a serious condition and is very treatable. Treatment works! Patients who have depression should be treated whether or not they are at a higher risk for stroke and other diseases.