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Americans back from captivity need decompression period
The recent release of three Americans from North Korea has raised the question of how to bring back those who have been incarcerated abroad.
Jason Rezaian is the Iranian-American journalist who was detained in Iran for a year and a half. He recently discussed how beneficial it was for him to have time away from the spotlight after his release. He also expressed concern that the current administration’s tendency to parade former hostages before cameras right after their release could interfere with their ability to heal from their ordeal.
“I was so thankful that I had the opportunity to spend some time alone and with my family before that happened to me,” he said.
When I was in the Army, I was involved in planning for the release of an American pilot shot down over North Korea. Later, I talked on the Larry King Live about American soldiers taken prisoner in the beginning of the Iraq War who were being returned to Fort Bliss, Tex. And now, another American has been released from captivity, this time from Venezuela; by evening that same day, he was meeting with the president – and the press – at the White House.
In planning for repatriation, the military has built on the experience of former prisoners of war (POWs); in doing so, it has learned the best way to bring home those who have been captured. This experience builds on lessons learned from the return of POWs from the Korean war, the Vietnam war, the Gulf War, and other hostilities, according to the Borden Institute, an agency of the U.S. Army Medical Department Center and School now based in Fort Sam in Houston, Tex.
Optimal repatriation usually involves a decompression period, now often at the Army hospital in Landstuhl, Germany. About 3 days are allotted for medical and psychiatric exams, debriefing with intelligence agencies, and reunions with family members. Returning service members also catch up on sleep and nutrition; “three hots and a cot” is the Army mantra for dealing with combat stress, and it also applies here.
The returning service members also are prepared for the glare of media publicity which will follow. They learn how to avoid comments that might embarrass them later. If they have been held captive for a long period of time, they are brought up to date on recent events and news.
To quote the Borden Institute, “Most repatriated POWs, including those from the Persian Gulf War, have had little experience dealing with the media. The media are a substantial stressor that can have lifelong effects if a later, ‘Wish-I-had-never-said,’ statement is broadcast around the world. It is very important to both shield the POW and his family from early intrusive media coverage and to offer training in the management of media requests. This was done routinely for the POWs of the Persian Gulf War. Reminding POWs and their families that it is perfectly acceptable for them to say, ‘No,’ can be a most important intervention.”
So I would urge the current administration to take those lessons into account as it plans for the return of American hostages and returnees.
Dr. Ritchie, a forensic psychiatrist with expertise in military and veteran’s issues, is chief of psychiatry at MedStar Washington Hospital Center.
The recent release of three Americans from North Korea has raised the question of how to bring back those who have been incarcerated abroad.
Jason Rezaian is the Iranian-American journalist who was detained in Iran for a year and a half. He recently discussed how beneficial it was for him to have time away from the spotlight after his release. He also expressed concern that the current administration’s tendency to parade former hostages before cameras right after their release could interfere with their ability to heal from their ordeal.
“I was so thankful that I had the opportunity to spend some time alone and with my family before that happened to me,” he said.
When I was in the Army, I was involved in planning for the release of an American pilot shot down over North Korea. Later, I talked on the Larry King Live about American soldiers taken prisoner in the beginning of the Iraq War who were being returned to Fort Bliss, Tex. And now, another American has been released from captivity, this time from Venezuela; by evening that same day, he was meeting with the president – and the press – at the White House.
In planning for repatriation, the military has built on the experience of former prisoners of war (POWs); in doing so, it has learned the best way to bring home those who have been captured. This experience builds on lessons learned from the return of POWs from the Korean war, the Vietnam war, the Gulf War, and other hostilities, according to the Borden Institute, an agency of the U.S. Army Medical Department Center and School now based in Fort Sam in Houston, Tex.
Optimal repatriation usually involves a decompression period, now often at the Army hospital in Landstuhl, Germany. About 3 days are allotted for medical and psychiatric exams, debriefing with intelligence agencies, and reunions with family members. Returning service members also catch up on sleep and nutrition; “three hots and a cot” is the Army mantra for dealing with combat stress, and it also applies here.
The returning service members also are prepared for the glare of media publicity which will follow. They learn how to avoid comments that might embarrass them later. If they have been held captive for a long period of time, they are brought up to date on recent events and news.
To quote the Borden Institute, “Most repatriated POWs, including those from the Persian Gulf War, have had little experience dealing with the media. The media are a substantial stressor that can have lifelong effects if a later, ‘Wish-I-had-never-said,’ statement is broadcast around the world. It is very important to both shield the POW and his family from early intrusive media coverage and to offer training in the management of media requests. This was done routinely for the POWs of the Persian Gulf War. Reminding POWs and their families that it is perfectly acceptable for them to say, ‘No,’ can be a most important intervention.”
So I would urge the current administration to take those lessons into account as it plans for the return of American hostages and returnees.
Dr. Ritchie, a forensic psychiatrist with expertise in military and veteran’s issues, is chief of psychiatry at MedStar Washington Hospital Center.
The recent release of three Americans from North Korea has raised the question of how to bring back those who have been incarcerated abroad.
Jason Rezaian is the Iranian-American journalist who was detained in Iran for a year and a half. He recently discussed how beneficial it was for him to have time away from the spotlight after his release. He also expressed concern that the current administration’s tendency to parade former hostages before cameras right after their release could interfere with their ability to heal from their ordeal.
“I was so thankful that I had the opportunity to spend some time alone and with my family before that happened to me,” he said.
When I was in the Army, I was involved in planning for the release of an American pilot shot down over North Korea. Later, I talked on the Larry King Live about American soldiers taken prisoner in the beginning of the Iraq War who were being returned to Fort Bliss, Tex. And now, another American has been released from captivity, this time from Venezuela; by evening that same day, he was meeting with the president – and the press – at the White House.
In planning for repatriation, the military has built on the experience of former prisoners of war (POWs); in doing so, it has learned the best way to bring home those who have been captured. This experience builds on lessons learned from the return of POWs from the Korean war, the Vietnam war, the Gulf War, and other hostilities, according to the Borden Institute, an agency of the U.S. Army Medical Department Center and School now based in Fort Sam in Houston, Tex.
Optimal repatriation usually involves a decompression period, now often at the Army hospital in Landstuhl, Germany. About 3 days are allotted for medical and psychiatric exams, debriefing with intelligence agencies, and reunions with family members. Returning service members also catch up on sleep and nutrition; “three hots and a cot” is the Army mantra for dealing with combat stress, and it also applies here.
The returning service members also are prepared for the glare of media publicity which will follow. They learn how to avoid comments that might embarrass them later. If they have been held captive for a long period of time, they are brought up to date on recent events and news.
To quote the Borden Institute, “Most repatriated POWs, including those from the Persian Gulf War, have had little experience dealing with the media. The media are a substantial stressor that can have lifelong effects if a later, ‘Wish-I-had-never-said,’ statement is broadcast around the world. It is very important to both shield the POW and his family from early intrusive media coverage and to offer training in the management of media requests. This was done routinely for the POWs of the Persian Gulf War. Reminding POWs and their families that it is perfectly acceptable for them to say, ‘No,’ can be a most important intervention.”
So I would urge the current administration to take those lessons into account as it plans for the return of American hostages and returnees.
Dr. Ritchie, a forensic psychiatrist with expertise in military and veteran’s issues, is chief of psychiatry at MedStar Washington Hospital Center.
COMMENTARY: STARRS’ call for more intensive follow-up valuable
I would like to provide some perspective on the recent article on the Army STARRS study.
The article, “Predicting Suicides After Psychiatric Hospitalization in U.S. Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)” (JAMA Psychiatry 2014 Nov. 12 [doi: 10.1001/jamapsychiatry.2014.1754]), is one of a series from this multicenter, multiyear study.
My observations focus on four areas: 1) the history behind this research effort, 2) what we learn from the results, 3) how can we change the way we treat service members based on the results? and 4) the change in accession standards.
This research effort was launched after the rate of suicides continued to rise. Then vice chief of staff, Lt. Gen. Peter Chiarelli was frustrated. He developed a contract with the National Institute of Mental Health to fund an ambitious research agenda that included examining all known suicides to find a way to reduce them.
At that time, I was the chief psychiatrist for the Army and was frankly cynical about the STARRS research. We already knew the risk factors for suicide: previous psychiatric or criminal history, relationship difficulties, problems at work, substance abuse, and access to firearms. But, being a good Army Soldier, I saluted and worked to make it happen. After all, maybe the research would bring some clinically useful revelations.
Lt. Gen. Chiarelli also wanted quick results, within a year. Fat chance, I would have muttered under my breath, had I not been a good Soldier.
So, what does the research tell us, 5 years after the inception? Frankly not much that a military psychiatrist does not already know about the risk factors for suicide in military members. However, the article in JAMA Psychiatry does quantify those risk factors mentioned above.
It also stresses the high risk for those recently psychiatrically hospitalized. Civilian as well as military psychiatrists already know that high-risk patients are the ones who get hospitalized. A caveat: Only 12% of Army suicides were post hospitalization.
However, for a military servicemember, the hospitalization may add to their stress, as it often contributes to an exit from the military. Exit may mean a loss of job, housing, health care, and identity.
What is the actionable intelligence from the article? By actionable intelligence, a military term, I mean here what can clinicians do differently as a result of the research? Do you hospitalize less? Probably not.
The authors suggest more posthospitalization interventions but are guarded in their recommendations. More intensive follow-up could lead to more stigmatization and contribute to an accelerated exit from the military.
Nevertheless, that recommendation is where the value of this article lies. The military system is highly stressed with many competing priorities. Many posts, but not all, have posthospitalization easy access to care. As the article recommends, and I concur, there should be more intensive follow-up. This can be done in many ways, including group settings; military members often prefer groups, as then they can help one another.
There is another subtext to the whole suicide discussion: In the early years of the wars in Iraq and Afghanistan, when the Army was desperate for recruits, it relaxed its accession standards. More came in with prior psychiatric diagnoses. Later, the standards were tightened again; those soldiers were disqualified.
The changes in accession standards often happen in times of conflict. It is not surprising that increases in behavioral health difficulties happen when recruiters are strapped for new recruits and take in marginal performers. Now that the military is drawing down, and it is harder to get into the military with a bad background, suicides in the active duty may taper, irrespective of all the research and suicide prevention programs.
So the article cements what we already knew: People with previous psychiatric problems are more likely to suicide. The question is what can we do about it?
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
I would like to provide some perspective on the recent article on the Army STARRS study.
The article, “Predicting Suicides After Psychiatric Hospitalization in U.S. Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)” (JAMA Psychiatry 2014 Nov. 12 [doi: 10.1001/jamapsychiatry.2014.1754]), is one of a series from this multicenter, multiyear study.
My observations focus on four areas: 1) the history behind this research effort, 2) what we learn from the results, 3) how can we change the way we treat service members based on the results? and 4) the change in accession standards.
This research effort was launched after the rate of suicides continued to rise. Then vice chief of staff, Lt. Gen. Peter Chiarelli was frustrated. He developed a contract with the National Institute of Mental Health to fund an ambitious research agenda that included examining all known suicides to find a way to reduce them.
At that time, I was the chief psychiatrist for the Army and was frankly cynical about the STARRS research. We already knew the risk factors for suicide: previous psychiatric or criminal history, relationship difficulties, problems at work, substance abuse, and access to firearms. But, being a good Army Soldier, I saluted and worked to make it happen. After all, maybe the research would bring some clinically useful revelations.
Lt. Gen. Chiarelli also wanted quick results, within a year. Fat chance, I would have muttered under my breath, had I not been a good Soldier.
So, what does the research tell us, 5 years after the inception? Frankly not much that a military psychiatrist does not already know about the risk factors for suicide in military members. However, the article in JAMA Psychiatry does quantify those risk factors mentioned above.
It also stresses the high risk for those recently psychiatrically hospitalized. Civilian as well as military psychiatrists already know that high-risk patients are the ones who get hospitalized. A caveat: Only 12% of Army suicides were post hospitalization.
However, for a military servicemember, the hospitalization may add to their stress, as it often contributes to an exit from the military. Exit may mean a loss of job, housing, health care, and identity.
What is the actionable intelligence from the article? By actionable intelligence, a military term, I mean here what can clinicians do differently as a result of the research? Do you hospitalize less? Probably not.
The authors suggest more posthospitalization interventions but are guarded in their recommendations. More intensive follow-up could lead to more stigmatization and contribute to an accelerated exit from the military.
Nevertheless, that recommendation is where the value of this article lies. The military system is highly stressed with many competing priorities. Many posts, but not all, have posthospitalization easy access to care. As the article recommends, and I concur, there should be more intensive follow-up. This can be done in many ways, including group settings; military members often prefer groups, as then they can help one another.
There is another subtext to the whole suicide discussion: In the early years of the wars in Iraq and Afghanistan, when the Army was desperate for recruits, it relaxed its accession standards. More came in with prior psychiatric diagnoses. Later, the standards were tightened again; those soldiers were disqualified.
The changes in accession standards often happen in times of conflict. It is not surprising that increases in behavioral health difficulties happen when recruiters are strapped for new recruits and take in marginal performers. Now that the military is drawing down, and it is harder to get into the military with a bad background, suicides in the active duty may taper, irrespective of all the research and suicide prevention programs.
So the article cements what we already knew: People with previous psychiatric problems are more likely to suicide. The question is what can we do about it?
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
I would like to provide some perspective on the recent article on the Army STARRS study.
The article, “Predicting Suicides After Psychiatric Hospitalization in U.S. Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)” (JAMA Psychiatry 2014 Nov. 12 [doi: 10.1001/jamapsychiatry.2014.1754]), is one of a series from this multicenter, multiyear study.
My observations focus on four areas: 1) the history behind this research effort, 2) what we learn from the results, 3) how can we change the way we treat service members based on the results? and 4) the change in accession standards.
This research effort was launched after the rate of suicides continued to rise. Then vice chief of staff, Lt. Gen. Peter Chiarelli was frustrated. He developed a contract with the National Institute of Mental Health to fund an ambitious research agenda that included examining all known suicides to find a way to reduce them.
At that time, I was the chief psychiatrist for the Army and was frankly cynical about the STARRS research. We already knew the risk factors for suicide: previous psychiatric or criminal history, relationship difficulties, problems at work, substance abuse, and access to firearms. But, being a good Army Soldier, I saluted and worked to make it happen. After all, maybe the research would bring some clinically useful revelations.
Lt. Gen. Chiarelli also wanted quick results, within a year. Fat chance, I would have muttered under my breath, had I not been a good Soldier.
So, what does the research tell us, 5 years after the inception? Frankly not much that a military psychiatrist does not already know about the risk factors for suicide in military members. However, the article in JAMA Psychiatry does quantify those risk factors mentioned above.
It also stresses the high risk for those recently psychiatrically hospitalized. Civilian as well as military psychiatrists already know that high-risk patients are the ones who get hospitalized. A caveat: Only 12% of Army suicides were post hospitalization.
However, for a military servicemember, the hospitalization may add to their stress, as it often contributes to an exit from the military. Exit may mean a loss of job, housing, health care, and identity.
What is the actionable intelligence from the article? By actionable intelligence, a military term, I mean here what can clinicians do differently as a result of the research? Do you hospitalize less? Probably not.
The authors suggest more posthospitalization interventions but are guarded in their recommendations. More intensive follow-up could lead to more stigmatization and contribute to an accelerated exit from the military.
Nevertheless, that recommendation is where the value of this article lies. The military system is highly stressed with many competing priorities. Many posts, but not all, have posthospitalization easy access to care. As the article recommends, and I concur, there should be more intensive follow-up. This can be done in many ways, including group settings; military members often prefer groups, as then they can help one another.
There is another subtext to the whole suicide discussion: In the early years of the wars in Iraq and Afghanistan, when the Army was desperate for recruits, it relaxed its accession standards. More came in with prior psychiatric diagnoses. Later, the standards were tightened again; those soldiers were disqualified.
The changes in accession standards often happen in times of conflict. It is not surprising that increases in behavioral health difficulties happen when recruiters are strapped for new recruits and take in marginal performers. Now that the military is drawing down, and it is harder to get into the military with a bad background, suicides in the active duty may taper, irrespective of all the research and suicide prevention programs.
So the article cements what we already knew: People with previous psychiatric problems are more likely to suicide. The question is what can we do about it?
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
COMMENTARIES: The mixed health risk communication for Ebola
Bushmeat. Bodily fluids. The homeless man, exposed to Ebola via Thomas Eric Duncan, who could not be found for 4 days in Dallas. Parents pulling their children from Dallas schools. Endless media stories.
From public officials: First, the chances of Ebola reaching our shores deemed an “unlikely event.” Then, the message that “we will stop it in its track.” Later, we get the message that officials are safeguarding all the contacts in Dallas.
Except for the homeless man, who allegedly rode in the same ambulance that was used to transport Mr. Duncan to a Dallas hospital. And now we have a health care worker who has apparently tested preliminarily positive.
We seem to be divided into two polarized opposites on communicating risk, and we need to find an accurate middle ground.
On one side, many of our colleagues say, “What is all the fuss about? Many more people will die of flu this year than Ebola.” Or at least they did, a week ago.
On the other side, the media, meanwhile, continue to highlight every known possible case of Ebola outside of West Africa. Reports of dead and dying are legion in Guinea, Liberia, and Sierra Leone. Those three countries are in crisis, and their health care workers are dying in droves.
More recently, the nurse who developed Ebola in Spain is fanning concerns among health care workers in developed countries. Health authorities euthanized her dog, although there is not a clear reason as to why.
Here in the United States, people from Africa report stigma and discrimination.
What is the middle ground?
• Do not belittle concerns. Recognize that this is both a medical and psychological crisis.
• Acknowledge that this is a major issue, not only for West Africa but for the world.
• Emphasize the importance of supporting the public health infrastructure, not only for Ebola but for flu, SARS, rhinovirus, AIDS, and other infectious diseases.
• Stress basic infection control procedures, such as good old hand washing, of course. Ensure that masks and gloves are widely available and that people wear them.
• Develop widely visible protocols in every single clinic and emergency room – including psychiatric clinics and ERs. The protocols would emphasize that individuals who present with fever should be screened for a travel history in themselves or their families. Those with potential exposure to Ebola need to get to the hospital.
• Develop Ebola capacity, which we are calling Ebola Epidemic Management Initiatives, for each jurisdiction. Local workgroups with representatives from physical and mental health and safety officials could initiate the process.
• Do not assume that all fevers from West Africa are Ebola. Such fevers could be indicative of malaria or any number of other diseases.
• Encourage social distancing from people who might have been exposed to Ebola in community settings.
Many practitioners and jurisdictions are following the recommendations listed above, but not enough, and not on a systematic basis. The above are basic principles of health risk communication and public health measures. We have learned them over the last 30 years; let us use them.
Michael D. McDonald, Dr.PH., coordinator of the Global Health Response and Resilience Alliance and chairman of Oviar Global Resilience Systems, Washington, contributed to this commentary.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
Bushmeat. Bodily fluids. The homeless man, exposed to Ebola via Thomas Eric Duncan, who could not be found for 4 days in Dallas. Parents pulling their children from Dallas schools. Endless media stories.
From public officials: First, the chances of Ebola reaching our shores deemed an “unlikely event.” Then, the message that “we will stop it in its track.” Later, we get the message that officials are safeguarding all the contacts in Dallas.
Except for the homeless man, who allegedly rode in the same ambulance that was used to transport Mr. Duncan to a Dallas hospital. And now we have a health care worker who has apparently tested preliminarily positive.
We seem to be divided into two polarized opposites on communicating risk, and we need to find an accurate middle ground.
On one side, many of our colleagues say, “What is all the fuss about? Many more people will die of flu this year than Ebola.” Or at least they did, a week ago.
On the other side, the media, meanwhile, continue to highlight every known possible case of Ebola outside of West Africa. Reports of dead and dying are legion in Guinea, Liberia, and Sierra Leone. Those three countries are in crisis, and their health care workers are dying in droves.
More recently, the nurse who developed Ebola in Spain is fanning concerns among health care workers in developed countries. Health authorities euthanized her dog, although there is not a clear reason as to why.
Here in the United States, people from Africa report stigma and discrimination.
What is the middle ground?
• Do not belittle concerns. Recognize that this is both a medical and psychological crisis.
• Acknowledge that this is a major issue, not only for West Africa but for the world.
• Emphasize the importance of supporting the public health infrastructure, not only for Ebola but for flu, SARS, rhinovirus, AIDS, and other infectious diseases.
• Stress basic infection control procedures, such as good old hand washing, of course. Ensure that masks and gloves are widely available and that people wear them.
• Develop widely visible protocols in every single clinic and emergency room – including psychiatric clinics and ERs. The protocols would emphasize that individuals who present with fever should be screened for a travel history in themselves or their families. Those with potential exposure to Ebola need to get to the hospital.
• Develop Ebola capacity, which we are calling Ebola Epidemic Management Initiatives, for each jurisdiction. Local workgroups with representatives from physical and mental health and safety officials could initiate the process.
• Do not assume that all fevers from West Africa are Ebola. Such fevers could be indicative of malaria or any number of other diseases.
• Encourage social distancing from people who might have been exposed to Ebola in community settings.
Many practitioners and jurisdictions are following the recommendations listed above, but not enough, and not on a systematic basis. The above are basic principles of health risk communication and public health measures. We have learned them over the last 30 years; let us use them.
Michael D. McDonald, Dr.PH., coordinator of the Global Health Response and Resilience Alliance and chairman of Oviar Global Resilience Systems, Washington, contributed to this commentary.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
Bushmeat. Bodily fluids. The homeless man, exposed to Ebola via Thomas Eric Duncan, who could not be found for 4 days in Dallas. Parents pulling their children from Dallas schools. Endless media stories.
From public officials: First, the chances of Ebola reaching our shores deemed an “unlikely event.” Then, the message that “we will stop it in its track.” Later, we get the message that officials are safeguarding all the contacts in Dallas.
Except for the homeless man, who allegedly rode in the same ambulance that was used to transport Mr. Duncan to a Dallas hospital. And now we have a health care worker who has apparently tested preliminarily positive.
We seem to be divided into two polarized opposites on communicating risk, and we need to find an accurate middle ground.
On one side, many of our colleagues say, “What is all the fuss about? Many more people will die of flu this year than Ebola.” Or at least they did, a week ago.
On the other side, the media, meanwhile, continue to highlight every known possible case of Ebola outside of West Africa. Reports of dead and dying are legion in Guinea, Liberia, and Sierra Leone. Those three countries are in crisis, and their health care workers are dying in droves.
More recently, the nurse who developed Ebola in Spain is fanning concerns among health care workers in developed countries. Health authorities euthanized her dog, although there is not a clear reason as to why.
Here in the United States, people from Africa report stigma and discrimination.
What is the middle ground?
• Do not belittle concerns. Recognize that this is both a medical and psychological crisis.
• Acknowledge that this is a major issue, not only for West Africa but for the world.
• Emphasize the importance of supporting the public health infrastructure, not only for Ebola but for flu, SARS, rhinovirus, AIDS, and other infectious diseases.
• Stress basic infection control procedures, such as good old hand washing, of course. Ensure that masks and gloves are widely available and that people wear them.
• Develop widely visible protocols in every single clinic and emergency room – including psychiatric clinics and ERs. The protocols would emphasize that individuals who present with fever should be screened for a travel history in themselves or their families. Those with potential exposure to Ebola need to get to the hospital.
• Develop Ebola capacity, which we are calling Ebola Epidemic Management Initiatives, for each jurisdiction. Local workgroups with representatives from physical and mental health and safety officials could initiate the process.
• Do not assume that all fevers from West Africa are Ebola. Such fevers could be indicative of malaria or any number of other diseases.
• Encourage social distancing from people who might have been exposed to Ebola in community settings.
Many practitioners and jurisdictions are following the recommendations listed above, but not enough, and not on a systematic basis. The above are basic principles of health risk communication and public health measures. We have learned them over the last 30 years; let us use them.
Michael D. McDonald, Dr.PH., coordinator of the Global Health Response and Resilience Alliance and chairman of Oviar Global Resilience Systems, Washington, contributed to this commentary.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
PTSD ‘updates’ in DSM-5 concerning
As a seasoned psychiatrist, I try to take most events in stride. My main reaction to unsettling events is to flatten down and take my own pulse.
However, when I saw the article in the Lancet Psychiatry (2014 Aug. 14 [doi:10.1016/S2215-0366(14)70235-4]) by my longtime colleague, Col. (Ret.) Charles W. Hoge, M.D., and his coauthors, my pulse went way up, and "Oh, my God" was my very unscientific reaction.
As readers may recall, the new definition of posttraumatic stress disorder raises the number of symptoms from 17 to 20, and 8 of those original symptoms were substantially reworded. In addition, PTSD was moved in the new manual from an anxiety disorder to disorders related to trauma and stressors.
In their study, Dr. Hoge and his coauthors administered surveys to soldiers looking at DSM-IV-TR and DSM-5 criteria. In brief, about a third of soldiers who met DSM-IV-TR criteria for PTSD did not meet DSM-5 criteria. Almost a third were in the opposite camp, meeting DSM-5 but not the older criteria, wrote Dr. Hoge of the Center for Psychiatry and Neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md. The main issue is about criterion C and the splitting up of avoidance symptoms from depressive symptoms.
Why was my reaction so strong? I had thought that the new criteria would widen those eligible for the diagnosis. Instead, it eliminates almost a third of them, mainly because they did not meet the avoidant criteria. (Please read the article for the full complex details.)
In the disability system in the military and Veterans Affairs system, the diagnosis of PTSD carries major weight. So what will happen if the criteria exclude them?
The good news is that both Veterans Affairs and the Department of Defense have made it clear that service members and veterans who already have the diagnosis according to the DSM-IV will not have it changed as a result of DSM-5, so the new definition mostly pertains to those newly seeking care or benefits now. It remains unclear what diagnosis should be used for those veterans who clearly would have met the previous definition (which has been used for more than 25 years), but not the new one. The DSM-5 recommends the use of adjustment disorder in this case, but some experts are concerned that the use of this diagnosis for this purpose will have negative effects. A major issue is that service members can be separated without benefits for an adjustment disorder. Questions also remain about whether adjustment disorder should have even been paired with PTSD in the same chapter in the new DSM-5.
In the accompanying commentary, Dr. Alexander C. McFarlane, of the Centre for Traumatic Studies at the University of Adelaide, Australia, warns about the negative consequences of the change in definition (Lancet Psychiatry 2014 Aug. 14 [doi:10.1016/S2215-0366(14)70321-9]. He also urges caution when the new diagnosis is used in forensic or disability evaluations.
I recommend that readers review this important article and commentary, and that the military and the VA also take a cautious approach.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.
As a seasoned psychiatrist, I try to take most events in stride. My main reaction to unsettling events is to flatten down and take my own pulse.
However, when I saw the article in the Lancet Psychiatry (2014 Aug. 14 [doi:10.1016/S2215-0366(14)70235-4]) by my longtime colleague, Col. (Ret.) Charles W. Hoge, M.D., and his coauthors, my pulse went way up, and "Oh, my God" was my very unscientific reaction.
As readers may recall, the new definition of posttraumatic stress disorder raises the number of symptoms from 17 to 20, and 8 of those original symptoms were substantially reworded. In addition, PTSD was moved in the new manual from an anxiety disorder to disorders related to trauma and stressors.
In their study, Dr. Hoge and his coauthors administered surveys to soldiers looking at DSM-IV-TR and DSM-5 criteria. In brief, about a third of soldiers who met DSM-IV-TR criteria for PTSD did not meet DSM-5 criteria. Almost a third were in the opposite camp, meeting DSM-5 but not the older criteria, wrote Dr. Hoge of the Center for Psychiatry and Neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md. The main issue is about criterion C and the splitting up of avoidance symptoms from depressive symptoms.
Why was my reaction so strong? I had thought that the new criteria would widen those eligible for the diagnosis. Instead, it eliminates almost a third of them, mainly because they did not meet the avoidant criteria. (Please read the article for the full complex details.)
In the disability system in the military and Veterans Affairs system, the diagnosis of PTSD carries major weight. So what will happen if the criteria exclude them?
The good news is that both Veterans Affairs and the Department of Defense have made it clear that service members and veterans who already have the diagnosis according to the DSM-IV will not have it changed as a result of DSM-5, so the new definition mostly pertains to those newly seeking care or benefits now. It remains unclear what diagnosis should be used for those veterans who clearly would have met the previous definition (which has been used for more than 25 years), but not the new one. The DSM-5 recommends the use of adjustment disorder in this case, but some experts are concerned that the use of this diagnosis for this purpose will have negative effects. A major issue is that service members can be separated without benefits for an adjustment disorder. Questions also remain about whether adjustment disorder should have even been paired with PTSD in the same chapter in the new DSM-5.
In the accompanying commentary, Dr. Alexander C. McFarlane, of the Centre for Traumatic Studies at the University of Adelaide, Australia, warns about the negative consequences of the change in definition (Lancet Psychiatry 2014 Aug. 14 [doi:10.1016/S2215-0366(14)70321-9]. He also urges caution when the new diagnosis is used in forensic or disability evaluations.
I recommend that readers review this important article and commentary, and that the military and the VA also take a cautious approach.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.
As a seasoned psychiatrist, I try to take most events in stride. My main reaction to unsettling events is to flatten down and take my own pulse.
However, when I saw the article in the Lancet Psychiatry (2014 Aug. 14 [doi:10.1016/S2215-0366(14)70235-4]) by my longtime colleague, Col. (Ret.) Charles W. Hoge, M.D., and his coauthors, my pulse went way up, and "Oh, my God" was my very unscientific reaction.
As readers may recall, the new definition of posttraumatic stress disorder raises the number of symptoms from 17 to 20, and 8 of those original symptoms were substantially reworded. In addition, PTSD was moved in the new manual from an anxiety disorder to disorders related to trauma and stressors.
In their study, Dr. Hoge and his coauthors administered surveys to soldiers looking at DSM-IV-TR and DSM-5 criteria. In brief, about a third of soldiers who met DSM-IV-TR criteria for PTSD did not meet DSM-5 criteria. Almost a third were in the opposite camp, meeting DSM-5 but not the older criteria, wrote Dr. Hoge of the Center for Psychiatry and Neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md. The main issue is about criterion C and the splitting up of avoidance symptoms from depressive symptoms.
Why was my reaction so strong? I had thought that the new criteria would widen those eligible for the diagnosis. Instead, it eliminates almost a third of them, mainly because they did not meet the avoidant criteria. (Please read the article for the full complex details.)
In the disability system in the military and Veterans Affairs system, the diagnosis of PTSD carries major weight. So what will happen if the criteria exclude them?
The good news is that both Veterans Affairs and the Department of Defense have made it clear that service members and veterans who already have the diagnosis according to the DSM-IV will not have it changed as a result of DSM-5, so the new definition mostly pertains to those newly seeking care or benefits now. It remains unclear what diagnosis should be used for those veterans who clearly would have met the previous definition (which has been used for more than 25 years), but not the new one. The DSM-5 recommends the use of adjustment disorder in this case, but some experts are concerned that the use of this diagnosis for this purpose will have negative effects. A major issue is that service members can be separated without benefits for an adjustment disorder. Questions also remain about whether adjustment disorder should have even been paired with PTSD in the same chapter in the new DSM-5.
In the accompanying commentary, Dr. Alexander C. McFarlane, of the Centre for Traumatic Studies at the University of Adelaide, Australia, warns about the negative consequences of the change in definition (Lancet Psychiatry 2014 Aug. 14 [doi:10.1016/S2215-0366(14)70321-9]. He also urges caution when the new diagnosis is used in forensic or disability evaluations.
I recommend that readers review this important article and commentary, and that the military and the VA also take a cautious approach.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.
Thoughts on the suicides of highly public figures
Suicides raise a lot of feelings in the survivors. By survivors, I mean family members, friends, coworkers, and health care providers. In the event of a public figure, such as Robin Williams, this also includes the general public.
Typically there is grief, loss, and guilt. "Why did I not know he or she was feeling so bad? Why did I not do more to prevent it?"
There is also anger, maybe or not expressed, from the family members: "How could he do this to me and/or the kids?"
From coworkers the same question, plus: "Will this reflect badly on our interactions?"
For health care workers, especially those who have taken care of the deceased: "Are my notes good enough? Will I be sued for inadequate care?"
Of course, there is always the question of "copycat" suicides, which especially trouble those in the school and correctional systems and the military.
And then we get the public reactions to the suicide of a public figure, such as Robin Williams.
So far the reactions in the media have all been laudatory about his work. Some have pointed to the need for better education about depression and addiction.
But many, including me, worry about the copycat effect. The burst of publicity and the connections to public figures who have taken their lives are concerning.
So I have my own anger about how this may contribute to other suicides, especially in younger impressionistic people.
What is the answer? No easy solutions here – other than talking about it.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.
Suicides raise a lot of feelings in the survivors. By survivors, I mean family members, friends, coworkers, and health care providers. In the event of a public figure, such as Robin Williams, this also includes the general public.
Typically there is grief, loss, and guilt. "Why did I not know he or she was feeling so bad? Why did I not do more to prevent it?"
There is also anger, maybe or not expressed, from the family members: "How could he do this to me and/or the kids?"
From coworkers the same question, plus: "Will this reflect badly on our interactions?"
For health care workers, especially those who have taken care of the deceased: "Are my notes good enough? Will I be sued for inadequate care?"
Of course, there is always the question of "copycat" suicides, which especially trouble those in the school and correctional systems and the military.
And then we get the public reactions to the suicide of a public figure, such as Robin Williams.
So far the reactions in the media have all been laudatory about his work. Some have pointed to the need for better education about depression and addiction.
But many, including me, worry about the copycat effect. The burst of publicity and the connections to public figures who have taken their lives are concerning.
So I have my own anger about how this may contribute to other suicides, especially in younger impressionistic people.
What is the answer? No easy solutions here – other than talking about it.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.
Suicides raise a lot of feelings in the survivors. By survivors, I mean family members, friends, coworkers, and health care providers. In the event of a public figure, such as Robin Williams, this also includes the general public.
Typically there is grief, loss, and guilt. "Why did I not know he or she was feeling so bad? Why did I not do more to prevent it?"
There is also anger, maybe or not expressed, from the family members: "How could he do this to me and/or the kids?"
From coworkers the same question, plus: "Will this reflect badly on our interactions?"
For health care workers, especially those who have taken care of the deceased: "Are my notes good enough? Will I be sued for inadequate care?"
Of course, there is always the question of "copycat" suicides, which especially trouble those in the school and correctional systems and the military.
And then we get the public reactions to the suicide of a public figure, such as Robin Williams.
So far the reactions in the media have all been laudatory about his work. Some have pointed to the need for better education about depression and addiction.
But many, including me, worry about the copycat effect. The burst of publicity and the connections to public figures who have taken their lives are concerning.
So I have my own anger about how this may contribute to other suicides, especially in younger impressionistic people.
What is the answer? No easy solutions here – other than talking about it.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.
Infectious disease and psychiatric morbidity
When I was in medical school, I was torn between going into infectious diseases – I had loved Rats, Lice, and History (Boston: Little, Brown & Co., 1935) – and psychiatry. I spent a month at the former Army facility, Gorgas Hospital, in Panama City, studying tropical diseases. I found that looking at slides under a microscope gave me headaches and ended up studying psychiatry at Walter Reed, which was in Washington at the time.*
But I remained fascinated by the intersection between tropical disease and their psychiatric manifestations. These included the neuropsychiatric manifestations of schistosomiasis – cysts in the brain – and the neurologic effects of Lyme disease and tetanus. But this was a relatively arcane area in the United States.
Then came the AIDS epidemic. AIDS showed both the connections between reckless behavior – casual sex, intravenous drug use – and the drastic effects of the virus on the brain. There was also the fear factor. Back when AIDS was new, medical students and doctors entered the hospital rooms in gowns, masks, and gloves. We feared the infected needle stick.
Now AIDS is a chronic disease, not a death sentence. If we are exposed, there are prophylactic medications.
Then there were the anthrax letters. Five died. Fear gripped the East Coast, as we wore gloves to open the mail.
But mundane antibiotics stopped the deaths. Our collective anxiety eased.
So enters Ebola virus in the news. Obviously, the spread of the disease in West Africa is very scary, especially with reports of doctors and other health care workers getting infected and dying.
NPR and other media outlets have interviewed Dr. Tom Frieden of the Centers for Disease Control and Prevention. He says the risk of transmission and infection in the United States is low. Still, there is the fear factor for both health care workers and the general public. Do we believe him or the other experts from CDC?
Some of the basic principles of health risk communication are: 1) do not just dismiss concerns; 2) convey what you know and don’t know; and 3) listen to the concerns of the audience.
Doctors, including psychiatrists, are an essential part of that risk communication. Thus the information in these articles on Ebola and HIV is critical for psychiatrists to know, so that we can be a soothing voice to treat the anxiety of the public.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
*Correction, 8/7/2014: An earlier version of this story misstated the location of the institution.
When I was in medical school, I was torn between going into infectious diseases – I had loved Rats, Lice, and History (Boston: Little, Brown & Co., 1935) – and psychiatry. I spent a month at the former Army facility, Gorgas Hospital, in Panama City, studying tropical diseases. I found that looking at slides under a microscope gave me headaches and ended up studying psychiatry at Walter Reed, which was in Washington at the time.*
But I remained fascinated by the intersection between tropical disease and their psychiatric manifestations. These included the neuropsychiatric manifestations of schistosomiasis – cysts in the brain – and the neurologic effects of Lyme disease and tetanus. But this was a relatively arcane area in the United States.
Then came the AIDS epidemic. AIDS showed both the connections between reckless behavior – casual sex, intravenous drug use – and the drastic effects of the virus on the brain. There was also the fear factor. Back when AIDS was new, medical students and doctors entered the hospital rooms in gowns, masks, and gloves. We feared the infected needle stick.
Now AIDS is a chronic disease, not a death sentence. If we are exposed, there are prophylactic medications.
Then there were the anthrax letters. Five died. Fear gripped the East Coast, as we wore gloves to open the mail.
But mundane antibiotics stopped the deaths. Our collective anxiety eased.
So enters Ebola virus in the news. Obviously, the spread of the disease in West Africa is very scary, especially with reports of doctors and other health care workers getting infected and dying.
NPR and other media outlets have interviewed Dr. Tom Frieden of the Centers for Disease Control and Prevention. He says the risk of transmission and infection in the United States is low. Still, there is the fear factor for both health care workers and the general public. Do we believe him or the other experts from CDC?
Some of the basic principles of health risk communication are: 1) do not just dismiss concerns; 2) convey what you know and don’t know; and 3) listen to the concerns of the audience.
Doctors, including psychiatrists, are an essential part of that risk communication. Thus the information in these articles on Ebola and HIV is critical for psychiatrists to know, so that we can be a soothing voice to treat the anxiety of the public.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
*Correction, 8/7/2014: An earlier version of this story misstated the location of the institution.
When I was in medical school, I was torn between going into infectious diseases – I had loved Rats, Lice, and History (Boston: Little, Brown & Co., 1935) – and psychiatry. I spent a month at the former Army facility, Gorgas Hospital, in Panama City, studying tropical diseases. I found that looking at slides under a microscope gave me headaches and ended up studying psychiatry at Walter Reed, which was in Washington at the time.*
But I remained fascinated by the intersection between tropical disease and their psychiatric manifestations. These included the neuropsychiatric manifestations of schistosomiasis – cysts in the brain – and the neurologic effects of Lyme disease and tetanus. But this was a relatively arcane area in the United States.
Then came the AIDS epidemic. AIDS showed both the connections between reckless behavior – casual sex, intravenous drug use – and the drastic effects of the virus on the brain. There was also the fear factor. Back when AIDS was new, medical students and doctors entered the hospital rooms in gowns, masks, and gloves. We feared the infected needle stick.
Now AIDS is a chronic disease, not a death sentence. If we are exposed, there are prophylactic medications.
Then there were the anthrax letters. Five died. Fear gripped the East Coast, as we wore gloves to open the mail.
But mundane antibiotics stopped the deaths. Our collective anxiety eased.
So enters Ebola virus in the news. Obviously, the spread of the disease in West Africa is very scary, especially with reports of doctors and other health care workers getting infected and dying.
NPR and other media outlets have interviewed Dr. Tom Frieden of the Centers for Disease Control and Prevention. He says the risk of transmission and infection in the United States is low. Still, there is the fear factor for both health care workers and the general public. Do we believe him or the other experts from CDC?
Some of the basic principles of health risk communication are: 1) do not just dismiss concerns; 2) convey what you know and don’t know; and 3) listen to the concerns of the audience.
Doctors, including psychiatrists, are an essential part of that risk communication. Thus the information in these articles on Ebola and HIV is critical for psychiatrists to know, so that we can be a soothing voice to treat the anxiety of the public.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
*Correction, 8/7/2014: An earlier version of this story misstated the location of the institution.
