Sometimes, retirement days get filled up and the everyday business of working life returns – a reminder of why one retires in the first place. The last few days have been like that – meetings, weddings, old friends not seen for years. But on the side of my mind, something about that speech of NIMH Director Tom Insel reported in my last post [class action in the air…] has been nagging at me. So last night, I sat down and read it again. Was it his perseveration on his renaming psychiatry as "clinical neuroscience" that was sticking with me?
“We are at an extraordinary moment when the entire scientific foundation for mental health is shifting, with the 20th century discipline of psychiatry becoming the 21st century discipline of clinical neuroscience,” Thomas Insel said before a meeting on the challenges facing mental health research at the Royal Society in London…
That does bother me – but it’s an elementary school playground, turf-war kind of bother. Nothing new. Was it that his list of "revolutionary changes":
• "chemical imbalance" is out. "brain circuitry" is in…
• "mental ill health was now recognised as a developmental disorder for which early intervention was vital"
• "the recognition that mental ill health is a complex mix of genetic and experiential factors. ‘This is not new,’ he affirmed. ‘But what is new is the ability to probe the genetics of the disorder.’ "
The first is spin on the failings of the last 25 years of "chemical imbalance" drug research – the last FutureThink didn’t pan out, so on to the new brain imaging FutureThink! The second is an allusion to Patrick McGorry’s early intervention in psychosis meme – now under fire. And finally, shades of the Personalized Medicine race between the Brain Resources drug company financed version [lead by Nemeroff, Schatzberg, Rush, and Guru Evian Gordon] and the NIMH initiative [lead by Madhukar Trivedi]. Those things bother me sure enough, but I’ve had my say about them [Godzilla vs. Ghidorah…, 3. when n=a few needs n=a few more…]. Slim Pickings for a revolution, but after all, Tom Insel is a politicians and has to have something to say. A better candidate for what was bothering me was his ending:
The consequences of the “remarkable lack of progress” in tackling mental illness effectively were legion, he said. Depression alone was the number one source of disability, he said. “The rate of suicide is way way beyond the rate of homicide in most of the world. In the US, it’s double the rate of homicides and higher than road traffic accidents,” he commented, adding that suicide killed more soldiers in the US military than enemy combat.
It was at the end of his speech, a signature ending for him [and many others] – pointing out the toll of mental illness as a way of underscoring the need for research and attention to the plight of the afflicted. It always grabs me when they do that – make a Public Health justification for whatever it is they’re talking about at the time. But as I reread it last night, I realized that it wasn’t my generic reaction to that. It was that last phrase that was gnawing at me.
His whole speech had been about clinical neuroscience and future breakthroughs – a plea for more brain research. But when he uses the fact "that suicide killed more soldiers in the US military than enemy combat" to make his point, my mind calls "foul!". I see that piece of information as an indictment of an abject failure of modern organized psychiatry [the American Psychiatric Association and the National Institute of Mental Health] rather than as something to use in a call to arms for more support for brain research.
In World War I, we learned from the trench warfare that prolonged, sustained combat causes epidemic mental illness – the longer the exposure, the worse it gets. It was erroneously called Shell Shock in that war. Then in World War II, we named it Combat Fatigue. In Viet Nam, it became PTSD. Our literature is filled with data supporting this intuitively obvious fact. So as Director of the National Institute of Mental Health, why in the hell wasn’t Tom Insel testifying to Congress and the Joint Chiefs about the insanity in their policy of letting [in fact incentivizing] our adolescents go back for five or more contiguous tours of duty in middle east wars – wars where they live with the constant knowledge that any person on the street might be another human bomb? It may be cleaner than the trenches, but psychologically it’s equally grim. Here’s a sample commentary from over a year ago:
From the invasion of Afghanistan until last summer, the U.S. military had lost 761 soldiers in combat there. But a higher number in the service — 817 — had taken their own lives over the same period. The surge in suicides, which have risen five years in a row, has become a vexing problem for which the Army’s highest levels of command have yet to find a solution despite deploying hundreds of mental-health experts and investing millions of dollars. And the elephant in the room in much of the formal discussion of the problem is the burden of repeated tours of combat duty on a soldier’s battered psyche.
The problem is exacerbated by the manpower challenges faced by the service, because new research suggests that repeated combat deployments seem to be driving the suicide surge. The only way to apply the brakes will be to reduce the number of deployments per soldier and extend what the Army calls "dwell time" — the duration spent at home between trips to war zones. But the only way to make that possible would be to expand the Army’s troop strength, or reduce the number of soldiers sent off to war…
When I landed on that final sentence in Insel’s speech, here’s how I know that it is what has been bothering me for a couple of days: I wanted to put my question up there marked in dark-colored, bold type into all capital letters too – anything to make it look like a typographical scream. And then I wanted to go off on a rant. Well, I’m going to wait for a bit instead to see if my rant can be stated more rationally in a later post. For this moment, I’ll end with the words of one of the British War Poets:
I knew a simple soldier boy…..
Who grinned at life in empty joy,
Slept soundly through the lonesome dark,
And whistled early with the lark.
In winter trenches, cowed and glum,
With crumps and lice and lack of rum,
He put a bullet through his brain.
And no one spoke of him again.
You smug-faced crowds with kindling eye
Who cheer when soldier lads march by,
Sneak home and pray you’ll never know
The hell where youth and laughter go.
Who grinned at life in empty joy,
Slept soundly through the lonesome dark,
And whistled early with the lark.
In winter trenches, cowed and glum,
With crumps and lice and lack of rum,
He put a bullet through his brain.
And no one spoke of him again.
You smug-faced crowds with kindling eye
Who cheer when soldier lads march by,
Sneak home and pray you’ll never know
The hell where youth and laughter go.
Suicide in the Trenches
Siegfried Sassoon 1918
Siegfried Sassoon 1918
Nice post Mickey. Thanks
Thank you for presenting the facts, sir.
Duane