When patients would be brought into this center as they are all over the world , the first thing that the trauma team would do is be sure that the ABC’s are under control. As every medical student knows this means:

• Airway control with cervical spine protection
• Breathing
• Circulation and control of hemorrhage

In fact this assessment and immediate care should have started during the first aid that was given to the injured patient. There may be a need for a breathing tube, replacement of blood and even emergency surgery to control bleeding. As soon as possible there will be assessment of the brain and nervous system as well as examination of the body for other injuries and damage.

The patient may or may not be conscious. If they are conscious it is possible that they may be in extreme pain. The important question that I want to focus on is whether they will receive adequate pain medication and how important is it that they receive it. I am not just talking about their care in the emergency room but I would like to address this question as applying to the patient’s entire stay in the hospital.

What Is Pain ?

Pain is an unpleasant sensory and emotional experience associated with tissue damage. Immediate pain may be caused by mechanical or chemical irritation or by tissue damage due to trauma, surgery, disease, debridement, physical therapy, ambulation or any movement. Continuous pain may occur from direct damage or stimulation to the nerve secondary to swelling edema, tissue movement etc.

Peripheral sensations of pain can actually be affected by emotions and the psychological state of the person experiencing the pain. This can be understood by the “Gate Theory“ of pain  which postulates that the pain impulse can be moderated by impulses originating in the emotional center of the brain as well as from the thinking portions of the brain. Obviously, sensations of pain can be altered by medications as well as emotions and thoughts.

Are Doctors and Nurses Trained to Treat Pain ?

About 17 years ago I co-authored a book with Margot Schoeps titled Psychological Care of the Burn and Trauma Patient . We used more than 20% of the book to discuss how to manage pain. We came up with various pain protocols for the management of acute pain after consulting with leading experts in the field. Even though we were mental health consultants, we did this because we knew that at least  1/3 of the 75 million traumatic injures in the U.S would result in moderate to severe pain and that more than 5 million critically ill patients in ICUs units especially those recovering from trauma or surgery would be expected to suffer from episodes of acute pain. We also know that many (but certainly not all) of the doctors managing these patients were not well trained in pain management. We also knew that this pain experience for many patients could have lingering long term psychological effects.

I am pleased to say that there is much more knowledge and know how in pain management today thanks to more sophisticated ER training programs, Pain Management fellowships and an increased sensitivity to pain in the new generations of physicians. Nursing education in pain management has also undergone changes. Pain is now considered one of the vital signs which should be taken, measured and recorded.

Psychological Aspects of Pain

A person may consciously focus on the pain as a symbol of the illness and of the threat to his or her life. A patient may use the pain unconsciously to try elicit a caring response from his or her environment (which includes the doctor and nurses). When pain is inadequately managed, the patient can develop a pain symptom complex which can lead to increasing anxiety, depression and  hostility. It has been shown that a good social relationship can lead to decreased perception of pain and the need for less pain medication

The pain experience during the acute treatment can become an important part of the subsequent post traumatic stress syndrome. Emotions related to pain can be incorporated into flashbacks dreams, avoidance syndrome and in the  physiological  hyper arousal which are the symptoms of PTSD. Pain may be a motivating factor in suicidal ideation

Under Treatment of Pain

Even when doctors and nurse know how to treat pain, it often is not adequately controlled. With the utilization of “as needed” pain orders or self administered pain medication pumps, patients are still under treated for pain. Medical and nursing staff as well as patients themselves (taking their cues from the doctors and nurses) will feel that is better for them if they can hold off  a little longer before taking the next dosage or additional pain medicine. There is often a misguided idea that patients taking pain medication for acute pain will become addicted to the medication and that this can be avoided by delaying or taking a little less pain medicine. This is not true. Patients very rarely become addicted to pain medication because they took it during the acute phase of their injury. Once they are in the recovery phase it is usually very easy to taper off the narcotic medication and switch to another non addicting drug before stopping completely. It is the chronic conditions, which most often  cause drug dependency.

Pain Can Influence Ethical Decisions

I recall one time I was on a panel discussing ethical issues in burn care. On the panel with me was a man who had recovered from a very large burn which left him blind although since he recovered from his burn injury he had become a very successful attorney, married and had two children. However he was making the point that at the time of his acute treatment which had to be quite extensive, with numerous surgical procedures and debridement, he had requested that he not receive the extensive life saving complicated  treatment and he be allowed to die. His wish was not granted and although he did not wish to die at present, he believed that his wishes should have been respected at the time of his acute treatment. I asked him during the question period whether his pain had been adequately controlled. He said no and I followed up by asking him if it had been controlled does he think that he would not have asked to be allowed to die. He thought about it for a long minutes and said “probably not“   .

]]> http://www.psychiatrytalk.com/2011/03/pain-with-major-trauma-injury/feed/ 1 http://www.psychiatrytalk.com/2010/09/psychological-issues-for-trapped-miners/ http://www.psychiatrytalk.com/2010/09/psychological-issues-for-trapped-miners/#comments Wed, 08 Sep 2010 07:21:25 +0000 Dr. Blumenfield, M.D. http://www.psychiatrytalk.com/?p=1261 I recently had a phone call from a reporter from the LA Times asking me if I had opinions about the psychological issues that miners trapped in Chile might be having in view of the fact they might be there for another 3 months.

I hadn’t previously thought about this issue and was glad to offer certain possibilities. After the phone call I kept reflecting on this issue. 33 men cut off from their families and the world  in a relatively small space. Except for telephone communication and thin tube which could bring them food and water as well as  whatever small items could fit through the small opening, they were isolated captives. I don’t know what trauma they experienced at the time of mine collapse and whether they had some moments where they felt their life was in immediate damage. We also don’t know whether they still continually fearful for their lives and safety. After all, they are miners and they know the potential pitfalls of the rescue mission being undertaken.

An Event Outside The Usual Human Experience

When people experience a traumatic event that is out of the usual human experience, especially when it is life threatening to themselves or others, that is the major ingredient for developing a post traumatic stress disorder. If they are trained as to what to expect and how to protect themselves, that may help mitigate the trauma. However, as our soldiers have learned, there is no way to guarantee immunity from post traumatic stress. Sensory and sleep deprivation can intensify their response to trauma . The continued presence of the threat to themselves will also exacerbate the psychological symptoms as will the reintroduction of the trauma or something that reminds the person of the trauma.

While the isolation in a mine for this long  duration of time appears to be unprecedented, there are certain situations  where observations have been made on people isolated for long periods of time even with the ability to communicate to the outside world.

Space Travel Provides Model of Prolonged Isolation

The Space program comes immediately to mind where astronauts and cosmonauts were isolated on space stations for long periods of time. Several years ago after one such space trip a Russian cosmonaut wryly remarked, “All the conditions necessary for murder are met if you shut two men in a cabin measuring 5 meters by 6 and leave them together for two months.” With a larger group there is less likely to be intense reactions between two individuals but it certainly can happen.  One report divided the various  psychological responses during prolonged periods in space  into three phases. During the first, which usually lasted about two months, people were busy adapting, usually successfully, to their new environment. In the second phase, there were clear signs of fatigue and low motivation. In the final phase the people could become hypersensitive, nervous and irritable.  In discussing the anticipated expedition to Mars experts have been concerned the ever-present possibility of death by small breach of the space ship by a meteorite or sun flare and how that will effect them. As mentioned above, the trapped miners may very well be attuned to the possibility of some dangerous event where no help could be offered to them

Life on Submerged Submarine or in the Antarctica for Long Periods

Other examples of people being isolated for prolonged periods of time are life aboard a submarine which is on a mission requiring prolonged submersion or life in a remote scientific camp in the Antarctica. The psychological problems which have been noted in these environments include concerns about a limited amount of resources, the unchanging social group, social isolation, limited communication with the outside world, a self-contained ecosystem, the constant sense of danger, physical confinement, lack of privacy, lack of separation between work and non-work, limited opportunity for variety and change, limited sensory deprivation, and dependence on machine-dominated environment. This pretty well defines the anticipated psychological challenges facing the trapped minors. One big difference with those people isolated in the Antarctica  – if one member of an Antarctica team got annoyed with another, he or she would have the whole continent to walk away and be separate for a while. Astronauts and the trapped miners, however, would be very confined with no escape from each other, and they would be very worried about the supply of air and water.

Provide Basic Necessities Plus a Little Extra and More if Possible

The first rule for treating people who may be potentially traumatized is to give them the basic necessities of life plus a little extra when possible. This means food, water, warm dry clothes (or in this case since it is warm down there, dry comfortable cool clothes). The next things that they need are information and communication. They have to have confidence in the people talking to them and know they are receiving honest information. People in a crisis, whether it is on a airliner having difficulty, being in a flood, hurricane or the target of an ongoing  terrorist attack all  want to know what is going on and what is planned for the immediate and near  term future. While they will respond best to truthful information, sometimes it doesn’t help them to give bad news if there is nothing they can do about it.  So for example, sometimes the death of family members is withheld if practical, from a trapped or isolated person until they are rescued. It goes without saying that speaking to loved ones during separation or during an ordeal is usually quite supportive. If a telephone line or radio signal is available a video link usually  can be set up. Providing music, tv shows and broadcasts of sporting events or other entertainment can be psychologically healthy for them also . I understand that some computer games, which are very small and can fit in the small opening, are also being provided. A particular social environment naturally develops with certain people becoming leaders. A 63 year old miner among those down there  has become the spiritual leader according to reports that I read. Recommendations can be made to the miners, which may be helpful. For example it is very important that they maintain a regular sleep cycle, which will be based on the clock rather than on seeing daylight outside. Another recommendation that I heard was being given to them to help maintain their civility and sociability is that they wait before starting their meals until the food for all the miners has been lowered.

Psychological Help During and After Being Trapped in the Mine

It will be feasible for the miners to have individual or group counseling session with mental health experts even while they are in the mine through the communication set up. If needed, psychotropic medications can be prescribed for various individuals and lowered into the mine. Regular chats with mental health professional while they trapped underground even if informal and brief will allow assessment of potential problems, which might require more intensive discussions or medication. I have read about the development of technology to help determine when someone on a phone line is in psychological distress just by their voice characteristics For example, computers can now discern the emotional inflection in a person’s voice to look for signs of emotional trouble. If the computer does find that someone is in need of help, it is programmed to suggest ways to alleviate the problem, such as recommending extra rest, extra food, or possibly medications or the live counselor could do so at that point. Unexpected crisis situations may occur and will have to be dealt with as they occur. One situation, which occurred recently in the Chile mine incident, was similar to situations I have occasionally seen when someone was unexpectedly brought to the hospital. A worried spouse and a girl friend meet each other for the first time as they rushed to the bedside (or in this case to the site of the mine collapse).

It is difficult to anticipate which members of the trapped group of miners will have more psychological issues than the others, both while in the mine and in the aftermath. Perhaps the best indication is whether they have had previous traumas and how they have dealt with them. This is certainly no guaranteed predictor of the future. Even the presence of severe mental illness doesn’t predict problems in this situation. During World War II in Europe there was   a diminished amount of exacerbation of existing mental disease as compared to during peacetime. One of the almost universal responses to an overwhelming trauma is to try to block it out, either by isolating the emotional reactions and/or the memory of traumatic event. People in the midst of traumatic event will report that it seemed as if it were happening to someone else. The degree to which they keep these memories and feelings out of their consciousness can be related to subsequent symptoms, which they may have. Most prominent among post traumatic symptoms are flashback, nightmares, being easily reminded of the trauma with reoccurring feelings or going out of the way to avoid such reminders. Some people resort to alcohol or drugs to try to avoid such painful feelings. Suicidal behavior is sometimes seen in people who feel overwhelmed by their experience and see no way for improvement. These problems when they do occur can be very brief and transient. They may not occur until after a period of weeks or several month from the time of rescue. They can persist for several months or even a lifetime if not treated.

CBT ( Cognitive Behavior Therapy ) has been used successfully in treating PTSD. This is a therapy which consists of correcting negative misperceptions about the experience but also teaching the patient various relaxation techniques at the same time as they mentally re-experience some of their traumatic memories. Other patients will benefit from therapy, which helps them explore the psychological meaning of this experience as well as deal with relationship issues and any resultant drug or alcohol problems.

Resiliency and The Joy of Being Alive

A few years ago I put together a conference of leading experts in psychological trauma and then edited a book with chapters by them on various aspects of disaster. Independently, in each of their presentations and in their book chapter they all made a point of discussing  the resiliency that most people have in dealing with traumatic events. Although many victims of such events greatly benefit by treatment and may have lingering symptoms, the major of  of people in such a situation will have the resiliency, to put this event into some perspective and return to their previous functioning.

Jose Luis Inciarte

Despite clinical experience that mental health professionals might have with people who have been through other traumatic situations, it is still hard to really imagine or empathize how these people are feeling. When I worked as consultant to a burn unit we would sometimes arrange a visit to a patient with a severe burn by a someone who had survived the ordeal that they had been through.

Just this week a Uruguayan rugby player who survived more than two month of isolation in the Andes with 15 others after a 1971 plane crash brought a message of hope for the miners. This survivor, Jose Luis Inciarte said, “They are in the process of discovering the joy of being alive and the will to survive.”

We Are Not More Dangerous to Ourselves Than The Enemy

As statistics such as these continue to emerge there is a continued outcry that something should be done about this. A report  issued by the US Army, in my opinion minimized the fact that these psychological causalities are a result combat and the realities of war. The Army review concluded “simply stated, we are often more dangerous to ourselves than the enemy” It went on to say that commanders have failed to identify and monitor soldiers prone to risk taking behavior and as a result suicides among soldier have soared. I believe that this is a misguided view that some somehow if we did the right thing we could prevent these events. There were 250 recommendations in the recent report and the Army has already implanted 240 of them. While these are positive things done to provide good mental health care, they  won’t prevent  PTSD and sadly it won’t eliminate suicides.

We haven’t been able to prevent the increasing number of Americans being killed by IEDs. War is hell and soldiers get killed. We train them the best way that we know how but inevitably soldiers die when there is a war. Maybe one soldiers, despite the best training available isn’t quite as good in a combat zone as another one. Some may be able to know when to zig rather than zag . Some have better instincts than others and that may make them more likely to survive. Some inherently may be able to handle the stress of war better than others.  However, the best training in the world and all the preventive measures in the world will not eliminate combat injuries and death. Nor can PTSD and suicides be avoided.   The most combat savvy soldiers in our military cannot hide from a  bullet with their name on it nor can the most well adjusted soldiers avoid  being  affected by extraordinary human experiences in a war zone.

Of course , we should always strive to improve our training, safety and efficiency in the battle field. Of course we should always strive to provide the best medical care (which includes psychological care) to our soldiers.

Soldiers Injured With  PTSD Deserves to Receive a Purple Heart

Families Deserve Presidential Condolence After Soldier Suicide

We honor our soldiers who are injured serving their country. We give “Purple Hearts“ to soldiers who have been wounded and bury with honor those who have given their lives for their country with the exception of those soldiers who suffer psychological injuries. There is no Purple Heart for them. There is no letter of condolence from the President to the families of those who died from suicide. This is outrageous!  These men and women have all volunteered and knew they could be in harms way. There is no basis for treating them as if they purposefully became psychological causalities. There is no way to minimize the grief of their loved ones but this failure to acknowledge their loss only compounds it.

My Mood Monitor is the Test

In a recent journal article in the Annuals of Family Medicine there is a report of the My Mood Monitor (M-3) a self administered 27 item check list that was tested on a sample of consecutive patients who were seeking primary care at the academic family medicine clinic at the University of North Carolina.  Those completing the M-3 were then contacted by a research assistant and asked to take the much longer 15 minutes Mini International Psychiatric Interview (MINI) by telephone in order to validate the results of the M3. The MINI is a well established test that has been validated against the Structured Clinical Interview for DSM  (SCID) which can take up to hour or even more time to administer by a trained person which is more or less the gold standard for research tools using the current psychiatric categories. In this particular study the MINI test results administered by phone were discussed with a psychiatrist before final scoring. If the M-3 is validated against the MINI and the MINI is validated against the SCID, they believe they have test which will be an accurate screening test.

Each of the 27 questions of the M-3  is answered by a check mark in a column which offers the responses:  Not at All, Rarely, Sometimes, Often , Most of the Time. Since just having a bunch of symptoms doesn’t necessarily mean that a person is having diagnosable condition or a serious problem, there were four questions, which assessed if there was a functional impairment. If there were no functional impairments of the person’s life style AND if the suicide question was negative, no further scoring was done and therefore no condition was identified

The test was not set up to pick up psychosis, dementia, marital, sexual or personality problems unless they would show up with significant anxiety or depression, which could very well be the case.

Results

Participants and Completers- 723 people, which were 54 % of the patients approached to participate, agreed to be in the study. 99% of this group also completed the MINI follow-up test.

Diagnosis According to the MINI Test- According to the MINI test, 22% of the people had a depressive disorder (16 % had a major depressive disorder, while 6% had bipolar disorder and 9.3%  had bipolar spectrum illness), 28.1% had an anxiety disorder and 6.3% had PTSD. Overall, 35% of the study participants met MINI criteria for at least one psychiatric diagnosis. 12.1 % had co-morbidity for anxiety and depression.

How Well Did the Brief M-3 Test Do? First of all 349 people (53%) were eliminated from being scored because they did not have a functional impairment. Of the 298 patients who were then scored using the M-3 (meaning that they had a functional impairment according to M-3), 62.4% met the criteria being used for a psychiatric diagnosis. Without going into detailed statistical analysis, it was found that the M3 showed a 95% confidence level for diagnosing depression and anxiety as well as PTSD with a sensitivity and specificity of about 80%. Most screening tools don’t integrate screening for bipolar and PTSD while screening for other anxiety and mood disorders, which is an added bonus. Overall, that is pretty darned good for a waiting room brief screening tool.

Added Benefits of the M-3

Additional questions about the process yielded information that 70 % of the participants reported talking to their clinician  about mood or feelings. 70% said they did so for at least one minute (certainly better than not at all). 63% of all participants reported that the M-3 helped them talk to their doctors about their mood or feelings. Among participants assigned a MINI diagnosis, 75% stated that the M-3 facilitated talking to their clinician about mood or feelings. 83 % of clinicians reviewed the checklist in 30 or fewer seconds. None found the M-3 too complicated and 80% thought it was helpful in reviewing participants’ emotional health.

Words of Caution

Anything that helps doctors become of aware of the patient’s emotional health has to be a good thing.

However, we must keep in mind that 46% of the people approached refused to participate in the study. That number is standard for research but any patient who refused to take a mental health screening test in a clinical practice should receive extra attention by the doctor.

53% people were not scored because even if they had positive symptoms, since they did not indicate that they had functional impairment or suicidal ideas. I hope that their physician would at least inquire about the symptoms, which were checked, and determine if the patient is having a problem and hasn’t yet come to the point of being impaired or is suicidal or perhaps just doesn’t want to readily acknowledge the severity of the problem.

The paper made a point that the M-3 had questions, which led to a distinction between major depression and bipolar depression. It was stated that the failure to do so can lead to the prescribing of antidepressants without a mood stabilizer, potentially destabilizing the illness and leading to the risk of hypomania, manic or mixed episodes. This is certainly true but I would hope that patients with first time bipolar disorder should ideally not be treated with mood stabilizers without psychiatric consultation. This condition can be difficult to manage and treatment is often not straightforward.

The diagnosis of any major depression may not only require medication, but also close monitoring, especially in the early phase of treatment. When there is the potential for suicidal ideation, an effective dosage of medication can increase the low energy of a depressed patient so they become more of suicidal risk than they were before starting medication.

Medications used for treating anxiety of course can be over used and create serious dependency issues.

Both anxiety and depression can be symptoms of underlying marital and other interpersonal problems as well personality disorders. PTSD once identified usually has complicated determinants and may not be easily treated by just medication.

The multidisciplinary team that put together the M-3 and the testing of it come from both Departments of Family Medicine and Psychiatry. As effective as these short diagnostic tools may be in identifying emotional problems for family physicians, they should be part a systematic approach to diagnosing and treating this condition. Family doctors need to spend more time with patients when these conditions are suspected, diagnosed and are being treated. It is also very important that physicians using the M-3 have a  collaborative relationship  with psychiatrists and other mental health professionals.

Is There A Role For Mental Health Professionals ?

Of course, at this time  there is a need for psychiatrists and other mental health professional in Haiti. However, everything is relative. After the terrorist attack in New York on 9/11 there was an abundance of mental health experts immediately available. They were put to work on the Pier 92, which was where the services for the victims were being organized. They were not assigned to do psychological therapy but rather assisted in helping the stunned people to get food, shelter and assist them in finding what happened to  their loved ones. Their psychological and interpersonal skills were no doubt helpful in carrying out these tasks even though most were not initially doing formal therapy.

Psychiatrists who have become involved in previous disasters often will write prescriptions for heart, thyroid, diabetic and mostly other non- psychiatric medications which people need and did not have .  (See my previous blog on this subject) Psychiatrists may also participate in the delivery of general medical care or even assist in surgery during the early stages of a disaster response.

We would hope that the people organizing and delivering the immediate care to the victims in Haiti are sensitive to the psychological vulnerabilities of the victims, especially the children involved. The leaders of emergency services also need to understand how important it is to provide truthful information to the people involved without inducing additional fears and anxiety. There are  special techniques to do these “risk communications”

In addition, the people doing death notifications to family and friends of those who died need to be knowledgeable and skilled in this difficult task.  Psychiatrists and other mental health professionals can be very helpful in training emergency workers for these tasks but the best time to do it is during emergency planning and  disaster preparedness.

Emotional Reactions in the Aftermath of Disaster

We all can imagine the fear and anxiety that people will initially feel when an earthquake occurs with immediate devastation. We can see the stunned look on the faces of the people in images from Haiti . It may take a while for the emotions to catch up with reality. In such a situation the people may become disconnected from their feelings (called dissociation).

Denial

Sometimes the people involved are actually denying the reality that has clearly occurred. In New York City immediately after the destruction of the World Trade Center thousands of people “disappeared”.  So many people did not come home that night and were buried in the rubble. Once it was established missing people were not registered at local hospitals, it should have been obvious that these people had perished. However families began posting “missing persons posters” all around Manhattan with a picture and a  description of the lost person with a phone number to call if the person were found. It took a week or two before the originators of most of these posters came back and changed the posters to memorials with people often putting flowers next to them. While this specific phenomena may not be occurring in Haiti, we can only imagine the difficulty that people are having adjusting to the sudden disappearance of important people in their lives. This is made even more difficult since, for most a funeral was not possible and for many the bodies will never be found.

Grieving

It was estimated that 10,000 children were grieving after the loss of a parent or a close relative following the 3000 deaths in the New York tragedy in 9/11. In Haiti more than 150,000 people are estimated to have died in this disaster so you can do the math as to acute grief among adults and children.  When people die violently, unexpected or when children are killed, the grieving that follows by their loved ones takes on special characteristics. It tends to be complicated by other psychiatric conditions such as post traumatic stress, major depression or even suicidal thoughts. Grieving in such situations tends to bring on alcohol and drug use in some people. It is more difficult to resolve all the powerful emotions especially the anger and the grief which can linger on for many years.

It is probably fair to say that the entire country of Haiti will be going through a prolonged grieving period but most people will not require psychological counseling even if it were available. The social networks including the church will provide most of the support. In fact, it has been shown that  following most disasters the majority of people will have great resiliency and will bravely deal with the tragedy albeit with a heavy heart. Their lives will be changed forever and they will never forget what happened. There will be memorials and anniversary events, which will be helpful to the grieving process.

Post Traumatic Stress

Having acknowledged the resiliency that most people will show after such mass trauma, many people will have at least some symptoms of post traumatic stress disorder ( PTSD). They will have recurrent and intrusive distressing recollections of the events that they have seen and been through. This can include nightmares and daytime flashbacks. At times people will act or feel as if the traumatic event were recurring. There may even be hallucinations or misperceptions where real things are misperceived as something related to the recent traumatic events. For example, the noise or vibrations of a passing plane or truck might immediately bring back a flood of the feelings that occurred during the earthquake. This can include rapid heart beat, fast breathing and other physical symptoms. When there are even mild after-shocks following a major earthquake some people are overwhelmed with emotion.

In the aftermath of such an event,  people suffering post traumatic stress symptoms can make efforts to avoid conversations or thoughts associated with the trauma. They may avoid certain locations or even people who will remind them of the recent trauma. Some will feel detached and estranged from other people and may not be able to have any loving feelings for a long time. There can be difficulty in falling or staying asleep, increased outbursts of anger, difficulty concentrating and hypervigilence. Quite characteristically people who are having symptoms of post traumatic stress will have an exaggerated startle response in which they can typically  appear to “jump out of their skin” after a loud or unexpected noise.

While at least 50 % of people exposed to the horrendous experience of a major earthquake can have one or more of these symptoms, perhaps only 10-15% will have significant symptoms lasting for more than one month in a pattern, which mental health professionals will diagnose as PTSD. Depending on the criteria used, some research has suggested higher numbers than I have stated above..

Treatment For Psychological Problems after a Traumatic Event

We have learned a great deal from past experiences, how to offer psychological help in the aftermath of a disaster. As previously mentioned, it is most important to assist with food shelter and help people find out about what happened to loved ones. In the past survivors were commonly offered a group technique called “critical incident stress debriefing (CISD)” where people were encouraged to relive their emotional experience in a supportive group environment. This technique has come under scrutiny as to whether it is the best technique or not and when and if  it should be used. Experience has taught disaster experts that while some group meetings maybe helpful, it is usually best to use them to provide survivors with needed information about coping with real issues as well some general information about the emotional reactions which they may be having, perhaps cautioning about the tendency in such a situation for some people to turn to alcohol and drugs. At the same time such meetings will allow mental health professionals to observe and identify the participants who may be doing poorly and require more specific individual or group therap. This treatment may be a specialized cognitive behavior type of treatment or more traditional psychotherapy

There has been some interesting research, which suggests that certain medications given during the early stage of disaster may prevent or minimize the development of posttraumatic stress symptoms. However at the present time medications of choice that are given are usually mild tranquilizers or sleep medication. Obviously people with severe symptoms or preexisting major mental disorders may require specific medications.

The Secondary Victims of Disaster

The psychological effects of a disaster not only potentially impact the people who live in Haiti or were there when the earthquake struck, but can also effect the emergency personnel who flowed into Haiti to provide services and who can  become secondary victims. This includes all the fire, police, rescue teams and military personnel as well as the many doctors, nurses, including mental health professionals. Even though many of these workers are used to seeing people who are traumatized, injured and dying or dead, the magnitude of this tragedy may be beyond anything that they have seen or experienced.

The Media Are Often Neglected as Potential Victims of PTSD

The other night I saw Anderson Cooper, CNN anchor, reporting from Haiti. He was telling about the dead bodies of children being pulled out of the rubble and other very difficult scenes. He was clearly emotionally affected. It is the job of the working press to view the worst of all the destruction, talk to victims, as well as the families of those who have perished. They often work around the clock without much rest. I have had experience working with media people who have been through disasters and I have seen the emotional toll that can be taken on them. (See Page 42-43 of this reference)

Conclusion

It will not be easy for the Haitian people to get through this tragedy without emotional scarring. I know that among the many volunteers assisting them and their helpers will be psychiatrists and other mental health professionals who will play an important role in the recovery from this ordeal.

Your Comments are Welcome

If an American soldier is wounded and then dies or is killed immediately in Iraq or Afghanistan,  the President of the United States and The Secretary of Defense write a condolence letter to the family. However, if an American soldier is wounded physically and /or psychologically during his action in Iraq or Afghanistan and then commits suicide there is no letter of condolence written to his or her family by the President and the Secretary of Defense.

There are now more suicides among our combat troops than all those killed by enemy fire in Iraq and Afghanistan together according to a recent CNN Report on this topic. There have been 354 suicides thus far in the year 2009 which is more than the 335 total of combat deaths which occurred in Iraq and Afghanistan combined . While most of the suicides don’t occur until the soldiers have returned to the states at least one third have taken place in Iraq and Afghanistan. The US Army and the National Institute of Mental Health are partnering to assess risk and resilience in service members in an epidemiologic study of mental health, psychological resilience, suicide risk, suicide-related behaviors, and suicide deaths. While this is quite important, it does not address the failure of our leaders to knowledge the sacrifice of those psychologically injured soldiers who commit  suicide. This is a serious defect in our moral fabric.

While Presidents since Lincoln have been writing letters of condolence to families, there is apparently unwritten policy that this does not include families of soldiers who have committed suicide. It is easy to imagine how hurtful that must be to a family who is burying a son or daughter who came back from war with psychological problems and then committed suicide or perhaps killed themselves while still overseas. The New York Times recently wrote a story about one such family. After Gregg and Janet Keesling’s son, Chancellor, killed himself in Iraq in June, the family received a folded flag, a letter from the Army praising their son, a 21-gun salute at his burial and financial death benefits, but not a letter of condolence from President Obama.

A spokesperson for President Obama said that the policy in regard to who should receive a letter of condolence is currently undergoing a review.

What is Going on Here?

I heard one report state that many soldiers would feel that their comrades combat death would be somehow demeaned if the families of soldiers who suicided were given an equal letter of condolence. Another view is that treating suicide the same as other war deaths might encourage mentally frail soldiers to take their lives by making the act seem honorable. These ideas may be influencing the thinking of some our military leaders and perhaps the President. I hope not.

If this is the case it is misguided thinking which resurrects the stigmatization of mental illness. These conditions are not something that anyone chooses to have. This includes depression, post traumatic stress disorder and traumatic brain injury all of which can be secondary to combat experiences. Soldiers cannot will themselves to avoid these conditions anymore than a soldier can avoid a bullet aimed at their head or an explosive device that goes off under their vehicle.  While training and good support can reduce the odds somewhat but once you are in a combat zone you are vulnerable to injury. I also know of no evidence that people on the verge of suicide would be driven to do it because their family would get a letter of condolence.

There is a famous cartoon which shows a therapist giving a patient a large slap in the face while saying “Snap out of it”  and the title of the cartoon is “One Session Therapy”. If there is humor in this, it is because some people have the phantasy that it is that easy to put aside psychological injury. Anyone with knowledge about mental illness and clinical experience knows that it is not true.

A soldier who suffers to the point of  ending his or her own life, has to be recognized as someone who has suffered as much as anyone can imagine.

As far as the idea that some deaths deserve a letter of condolence and some don’t, consider this. If a soldier in Iraq is working in the kitchen and the stove catches fire leading to his demise, would this death be any less deserving of a letter of condolence than a soldier who was caught in an enemy ambush? Would the loss be any less deserving of the latter soldier if it turned out that he made a foolish tactical error leading to his being killed as compared to someone who was brave enough to fall on a grenade to save others lives? Of course not. Similarly, would you compare a soldier who faced many horrific combat situations and developed PTSD with another soldier who became severely depressed shortly after his  plane just  touched down in the combat zone if both ended up having intolerable suicidal feelings which led to their death? Would one family be deserving of a letter of condolence and another not? I don’t believe that we judge some soldiers deaths as being more worthy than others.

Yes, we do give out special medals and recognition  for unusual acts of bravery but these in no way diminish the sacrifice that others have made.

They Are All Heroes

All of the soldiers that we have discussed above would have volunteered to serve in the military and today everyone knows that this most likely could mean exposure to combat. For this they deserve our thanks and when they and their families have made the supreme sacrifice they deserve at least a letter of condolence.

Action to Fix This Situation

What can we do to see that the families of soldiers who have suicided be given the same letter of condolence as families of other soldiers who have died in the military?

We can a write a letter to the President of the United States, Secretary of Defense and our Congressperson and US Senator. Those of you who are mental health professionals should clearly state this in such correspondence and explain how you feel about this situation especially based on your understanding of mental illness. The email address to write to the President is :       president@whitehouse.gov       There is every indication your email would be read by his staff and a sample of them are often shown to the President.  If many of the readers of this blog were to write him a note it is bound to make an impression as this issue is under consideration by the President at present. If you would like some tips on how to write to the President I found this brief article .

We should also ask our professional organizations if they have not done so already to weigh in on this matter. I am writing a letter to my colleague Dr. Alan Schatzberg, President of the American Psychiatric Association (APA), requesting him to consider asking the Board of Trustees to pass such a resolution if this has already not been done. This last November I finished my term as Past Speaker of the Assembly of the American Psychiatric Association and left the Assembly. So while I cannot sponsor such a resolution myself anymore,  I will ask my former colleagues there to also consider doing so . Both the Board of Trustees and the Assembly must approve position statements in the APA. I would hope that once this organization takes it on they will be able enlist the support of our colleagues in the American Medical Association as well as other professional groups.

By all indications President Obama is a compassionate person and I believe that once he has the facts and has heard from the public including mental health professionals, he will do the right thing.

I welcome your comments on this issue.