Tending to Veterans’ Afflictions of the Soul

By Samuel J. Freedman
The New York Times
Originally published January 13, 2013

Here are some excerpts:

Moral injury might best be defined as an affliction of the soul, as distinct from a specific mental health condition like post-traumatic stress disorder. It arises, to speak in a very broad way, from the way a combatant’s actions in war seem to violate and thus undermine the most deeply held moral beliefs.

Ms. Brock did not formulate the concept of moral injury, which is attributed to the clinical psychiatrist Jonathan Shay. In books like “Achilles in Vietnam,” Dr. Shay has traced moral injury back as far as the Trojan War. But for Ms. Brock and her colleagues, the kind of counterinsurgency wars America has fought in Iraq and Afghanistan has left soldiers uniquely vulnerable to moral injury.

“There’s no good choice,” she said. “If you’re looking at a kid on the side of the road with something in his hand, if it’s a grenade and he throws it and kills someone in your unit, you’ve failed your comrade. But if it’s a rock, you’ve just shot a kid with a rock.
“If you’re praying that your company gets out or that your best friend isn’t shot, and it doesn’t turn out that way, it can collapse your whole moral system. It feels like God abandoned you.”

Her description closely matched that of Michael Yandell, 28, a student at the Brite seminary who worked on a bomb disposal team during the Iraq war. “Most deeply, it’s a loss of confidence in one’s own ability to make a moral judgment with any certainty,” he said. “It’s not that you lose your ability to tell right from wrong, but things don’t seem so clear any more. For me, it’s whether or not what I did, did any good.”

Ms. Brock’s affinity for veterans, and her knowledge of their suffering, has long, deep roots. Her father, Roy Brock, was taken prisoner during World War II and underwent electroshock treatments after liberation for his psychological distress. He later served two tours in Vietnam as a medic, enduring the deaths not only of countless soldiers but the local translator he had befriended.

The entire story is here.

Building a Space for Calm

By ROGER S. ULRICH
The New York Times
Published: January 11, 2013

Here are some excerprts:

Efforts to reduce violence in psychiatric hospitals have focused on identifying potentially aggressive patients through clinical histories and improving staff training and care procedures. But these approaches, while worthy, are clearly not enough. While definitive numbers are hard to come by, the incidence of violence in care facilities appears to be going up.

Research suggests, however, that there’s an effective solution that has largely been overlooked: designing hospital spaces that can reduce human aggression — to calm emotionally troubled patients through architecture.

Currently, questions about design at psychiatric care facilities are viewed through the prism of security. How many guard and isolation rooms are needed? Where should we put locked doors and alarms? But architecture can — and should — play a much larger role in patient safety and care.

One prominent goal of facility design, for example, should be to reduce stress, which often leads to aggression.

For patients, the stress of mental illness itself can be intensified by the trauma of being confined for weeks in a locked ward. A care facility that’s also noisy, lacks privacy and hinders communication between staff and patients is sure to increase that trauma. Likewise, architectural designs that minimize noise and crowding, enhance patients’ coping and sense of control, and offer calming distractions can reduce trauma.

Thanks to decades of study on the design of apartments, prisons, cardiac intensive care units and offices, environmental psychologists now have a clear understanding of the architectural features that can achieve the latter — and few of these elements, if incorporated into a hospital design from the outset, significantly raise the cost of construction.

Providing day rooms and other shared spaces with movable seating, for example, gives patients the ability to control their personal space and interactions with others. Sound-absorbing surfaces reduce noise (and stress), as do designs that offer more natural light.
Some features, like single-patient bedrooms with private toilets, do increase the building cost — but that is arguably offset by the reduced trauma for patients and hospital workers. Violence, after all, isn’t just a danger to well-being, its effects — from medical care to lawsuits — are frequently expensive, too.

The entire story is here.

Thanks to Gary Schoener for this story.

There is more to end-of-life practices than euthanasia — Authors' reply

The Lancet
Volume 381, Issue 9862, Pages 202-203

Bregje Onwuteaka-Philipsen, Arianne Brinkman-Stoppelenburg, Hans van Delden, Anges van der Heide

We agree with Jan Schildmann and Eva Schildmann that the debate on end-of-life practices should not be limited to euthanasia. We also agree that increased attention to palliative care does not necessarily result in good quality end-of-life care. Our study gives an insight into end-of-life decision making and end-of-life acts, but not into the quality of end-of-life care. Additionally, what good quality end-of-life care consists of is not that straightforward. This is certainly true for palliative sedation. Although there is an increasing body of published studies on this subject, there are controversies on terminology and ethical acceptability of the practice. Guidelines are a way to try to overcome this and to improve quality of care. Yet there are many different guidelines—eg, at the institutional level and in different countries—and the premises of national guidelines can be the subject of debate. In our opinion, the role of empirical studies such as ours is to underpin the ongoing debate with information about what occurs in practice.

We declare that we have no conflicts of interest.

doi:10.1016/S0140-6736(13)60087-2

U.S. could save $2 trillion on health costs - study

By David Morgan
Reuters
Originally published January 10, 2012


The United States could save $2 trillion in healthcare spending over the next decade, if the U.S. government used its influence in the public and private sectors to nudge soaring costs into line with economic growth, a study released on Thursday said.

Compiled by the nonpartisan Commonwealth Fund, the study recommends holding the $2.8 trillion U.S. healthcare system to an annual spending target by having Medicare, Medicaid, other government programs and private insurers encourage providers to accelerate adoption of more cost-effective care.

Such a plan would require new legislation from a bitterly divided U.S. Congress, where Republicans would likely oppose new government controls, despite claims by the study's authors that families, employers and government budgets would receive long-sought relief from their growing financial healthcare burdens if the changes were enacted.

But Commonwealth Fund President Dr. David Blumenthal, a former healthcare adviser to President Barack Obama, said the approach could find bipartisan support in upcoming deficit talks as an alternative to cutting so-called entitlement programs including Medicare, the popular healthcare program for the elderly and disabled.

"In comparison with what some of those proposals advocate, we think that some of what we're proposing will look like an escape valve," Blumenthal told reporters in a conference call.

The United States has the world's most expensive healthcare system, which government forecasters say will cost more than $9,200 this year for every man, woman and child. Spending growth has slowed in recent years, but costs continue to outpace inflation and restrain overall economic growth.

The entire article is here.

Wealth but not health in the USA

The Lancet
Volume 381, Issue 9862
Page 177


Last week, American people, health-care workers, and policy makers received shocking news. Despite spending more on health care per person than other high-income countries, Americans die sooner, are least likely to reach the age of 50 years, and have higher rates of disease or injury. When judged by health alone, Americans are less healthy from birth to 75 years of age than people in 16 other economically wealthy countries, and this health disadvantage has been getting worse for 30 years, especially among women.

In a report released on Jan 9 from the US National Research Council and Institute of Medicine, U.S. Health in International Perspective: Shorter Lives, Poorer Health, comprehensive mortality and morbidity data are presented, comparing the USA with affluent democratic countries including Australia, Canada, France, Italy, most of the Nordic countries, Spain, and the UK. Life expectancy is shorter at birth for American men than for men in any of the other 16 countries, and American women fare little better—Denmark is the only country that has a lower life expectancy for women at birth. In nine key areas of health, Americans fare least well, or are near the bottom of the tables. These areas are: infant mortality and low birthweight; injuries and homicides; teenage pregnancies and sexually transmitted infections; HIV/AIDS prevalence; drug-related deaths; obesity and diabetes; heart disease; chronic lung disease; and disability. This health disadvantage applies to those with health insurance, a college education, higher incomes, and healthy behaviours as well as to those without.

Some good news in the report is that those Americans who reach 75 years live longer than their peers in other countries, and that Americans have low death rates from stroke and cancer. Moreover, current smoking rates are low, which should lead to future health benefits, and household income is relatively high.

US health spending was US$2·7 trillion in 2011, which is $8700 for every person in the country, and represents 17·9% of the economy—far greater than any other economically advanced country. But spending on health care bears little relation to good health.

Why are Americans at a health disadvantage compared with those in other countries? The fragmented US health-care system, and, in particular, poor access to health care and to primary care, are partly to blame....

The entire story is here.

Suspect in Killings Is Deemed Not Fit

By THE ASSOCIATED PRESS
Published: January 7, 2013

A judge ruled on Monday that a man accused of killing seven people at a small Christian college in Oakland is not mentally fit for trial.

Judge Carrie Panetta of Alameda County Superior Court temporarily suspended the case against One L. Goh after two psychiatric evaluations concluded that he had paranoid schizophrenia.

David Klaus, an Alameda County assistant public defender, said after Monday’s hearing that Mr. Goh’s condition causes him to have hallucinations and delusions and to distrust people, including those trying to help him. Mr. Goh’s lawyers have trouble talking to him, Mr. Klaus said.

The rest of the story is here.

Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents

Results From the National Comorbidity Survey

Matthew K. Nock, PhD; Jennifer Greif Green, PhD; Irving Hwang, MA; Katie A. McLaughlin, PhD; Nancy A. Sampson, BA; Alan M. Zaslavsky, PhD; Ronald C. Kessler, PhD

JAMA Psychiatry. 2013;():1-11. doi:10.1001/2013.jamapsychiatry.55.

ABSTRACT

Context
Although suicide is the third leading cause of death among US adolescents, little is known about the prevalence, correlates, or treatment of its immediate precursors, adolescent suicidal behaviors (ie, suicide ideation, plans, and attempts).

Objectives
To estimate the lifetime prevalence of suicidal behaviors among US adolescents and the associations of retrospectively reported, temporally primary DSM-IV disorders with the subsequent onset of suicidal behaviors.

Design  
Dual-frame national sample of adolescents from the National Comorbidity Survey Replication Adolescent Supplement.

Setting
Face-to-face household interviews with adolescents and questionnaires for parents.

Participants
A total of 6483 adolescents 13 to 18 years of age and their parents.

Main Outcome Measures
Lifetime suicide ideation, plans, and attempts.

Results 
The estimated lifetime prevalences of suicide ideation, plans, and attempts among the respondents are 12.1%, 4.0%, and 4.1%, respectively. The vast majority of adolescents with these behaviors meet lifetime criteria for at least one DSM-IV mental disorder assessed in the survey. Most temporally primary (based on retrospective age-of-onset reports) fear/anger, distress, disruptive behavior, and substance disorders significantly predict elevated odds of subsequent suicidal behaviors in bivariate models. The most consistently significant associations of these disorders are with suicide ideation, although a number of disorders are also predictors of plans and both planned and unplanned attempts among ideators. Most suicidal adolescents (>80%) receive some form of mental health treatment. In most cases (>55%), treatment starts prior to onset of suicidal behaviors but fails to prevent these behaviors from occurring.

Conclusions  
Suicidal behaviors are common among US adolescents, with rates that approach those of adults. The vast majority of youth with suicidal behaviors have preexisting mental disorders. The disorders most powerfully predicting ideation, though, are different from those most powerfully predicting conditional transitions from ideation to plans and attempts. These differences suggest that distinct prediction and prevention strategies are needed for ideation, plans among ideators, planned attempts, and unplanned attempts.

The original research is here.

A Clinical Trial and Suicide Leave Many Questions: Part 4: The University of Minnesota’s Response

By Judy Stone | January 8, 2013
Scientific American

Demystifying drug development, clinical research, medicine, and the role ethics plays

In earlier posts, we’ve looked at issues of consent, investigator responsibilities, and conflicts of interest on the case of Dan Markingson’s suicide while participating in a clinical trial of anti-psychotics at the University of Minnesota. This time, we turn to the University’s response.

 Not surprisingly, the University has claimed it has no responsibility for any wrongdoing—that in fact, no wrongdoing even occurred. But there are some inconsistencies in the story and unanswered questions. There is also concern over how the University has responded to criticism. We’ll examine these issues in this post.

Background regarding the University’s response

In response to the Minnesota Board of Social Work’s “corrective action” vs. Jeanne Kenney, the social worker/study coordinator who did most of the study assessments on Markingson, the UMN’s General Counsel Mark Rotenberg stated, “As we’ve stated previously, the Markingson case has been exhaustively reviewed by federal, state and academic bodies since 2004. The FDA, the Hennepin County District Court, the Minnesota Board of Medical Practice, the Minnesota Attorney General’s Office and the University’s Institutional Review Board have all reviewed the case. None found fault with the University. None found fault with any of our faculty. Most importantly, none found any causal link between the CAFE trial and the death of Mr. Markingson.”

Yet a number of UMN faculty have remaining concerns and have requested an independent investigation. Two years ago, eight faculty members in the Bioethics Department wrote Rotenberg, citing the University’s conflicts of interest in the matter. The UMN declines to reexamine the case, saying that they have been exonerated. In October 2012, Dr. Carl Elliott, Professor in the UMN Center for Bioethics, wrote Dr. Debra DeBruin, director of the Clinical Research Ethics Consultation Service for the UMN Clinical and Translational Science Institute, again requesting a review. This time Dr. Elliott expressed concern regarding human subjects protections in other trials conducted by the psychiatry department as well. As always, Dr. Elliott’s concerns were thoroughly documented. Once again, the University has turned away.

The entire story is here.

Thanks to Tom Fink for this story.

Military suicides hit record in 2012, outpace combat deaths

Reuters
Originally published January 14, 2013

The number of U.S. troops committing suicide set a record in 2012, exceeding the number of combat deaths, the Pentagon said on Monday.

The Pentagon said 349 active-duty troops killed themselves in 2012, up more than 15 percent from 2011 despite renewed efforts by the military to stem the suicide rate.

"This is an epidemic that cannot be ignored," said Senator Patty Murray, who championed legislation last year to improve suicide prevention efforts and mental health care for troops and veterans.

"As our newest generation of servicemembers and veterans face unprecedented challenges, today's news shows we must be doing more to ensure they are not slipping through the cracks."

The Army, as the largest service, counted the biggest number of suicides, with 182 soldiers killing themselves in 2012, according to preliminary figures. The Navy had 60 suicides, the Air Force had 59 and the Marines had 48.

The figures were first reported by the Associated Press.

The Pentagon pointed to steps to bolster suicide prevention efforts, including expanding a suicide prevention hotline. Still, Defense Secretary Leon Panetta last year acknowledged that the suicides were the most frustrating issue he had faced since taking over the Pentagon in 2011.

"Despite the increased efforts, the increased attention, the trends continue to move in a troubling and tragic direction," Panetta told at a joint Pentagon-Department of Veterans Affairs suicide prevention conference in June.

The entire story is here.