Huxley here we come

(from Time magazine) While the headline-grabbing weapons in this war have been high-tech wonders, like unmanned drones that drop Hellfire missiles on the enemy below, troops like LeJeune are going into battle with a different kind of weapon, one so stealthy that few Americans even know of its deployment. For the first time in history, a sizable and growing number of U.S. combat troops are taking daily doses of antidepressants to calm nerves strained by repeated and lengthy tours in Iraq and Afghanistan.

The medicines are intended not only to help troops keep their cool but also to enable the already strapped Army to preserve its most precious resource: soldiers on the front lines. Data contained in the Army’s fifth Mental Health Advisory Team report indicate that, according to an anonymous survey of U.S. troops taken last fall, about 12% of combat troops in Iraq and 17% of those in Afghanistan are taking prescription antidepressants or sleeping pills to help them cope. Escalating violence in Afghanistan and the more isolated mission have driven troops to rely more on medication there than in Iraq, military officials say. (go to article)

This is a sticky problem, isn't it? Leaving one's opinions about the wars in Iraq or Afganistan aside...and leaving aside as well my own strong bias against the overuse of medication in psychiatry, what IS the problem here? Soldiers are a resource that need to be managed; their returning home exhausted and traumatized serves nobody's interest, right?

Here is some research on a drug, known commercially as Inderal:

[Pitman] and his colleagues tested a tongue-twister of a drug called propranolol on 41 people who had experienced automobile accidents, assaults, and other traumas serious enough for them to be treated at the emergency room of Massachusetts General Hospital in Boston. The goal was to see if this drug, given within six hours of their mishaps, would prevent terrifying, indelible memories.

Tested three months after an auto accident, one young man, who took a dummy pill as part of the experiment, was still wary about getting into a car. He had nightmares. He sweated, his heart rate jumped, and he felt nervous anytime he got behind the wheel, especially in the area where the accident occurred.

In contrast, others who survived similar accidents and took propranolol had significantly fewer problems.

The most revealing tests were done three months after the traumas, when 22 of the victims returned to Mass General Hospital for evaluation. Eight of these people took propranolol four times a day for 10 days, but had been off the drug for more than two months when tested. Fourteen of the 22 had taken dummy pills, or placebos.

All of them listened to audiotapes on which they had described the incidents that brought them to the emergency room. None of those who took propranolol showed strong responses to the tapes. But eight of the placebo patients were obviously shaken by reliving their traumas. Their heart rates increased, their palms sweated, their muscles twitched - all signs of PTSD.

From 1988 to around 1994 I worked in a somewhat innovative program in Boston that treated young children (6-12) who suffered from a wide range of abuse. Violence was the texture of much of their young lives, and of course there was a great deal of sexual abuse. It was quite common for a kid to get really wound up and seek some sort of conflict; often it ended with the child being physically restrained. When I write "innovative" I mean for its time. It was a loving, caring place, but one that put far too much emphasis on such unbounded concepts as "cerebral dysfunction". Its strength was its staff, especially the nurses. But the conceptual framework was, to be sure, weak.

The kids were viewed, conceptually, as damaged. They certainly faced a myriad of extreme disadvantages, and these were compounded, I believe, by the behavioral scheme that attempted to reinforce and reward all kinds of actions, at the expense of a more natural, genuine setting. Once they left, it was likely that they moved into a world that responded to them in a totally different manner. What they learned they left behind, unless they wound up in a good school, with a good family, and a fierce advocate to protect them throughout the brutal foster care system.

But one thing that worked was Inderal. Inderal is a beta-blocker. More specifically, a beta-adrenergic antagonist that blocks the body's use of epinephrine. It puts a ceiling on how excited or overstimulated you can get. We used it to cut the cycle of violent outbursts that made any kind of therapeutic learning impossible. It was relatively safe- so long as the patient's blood pressure was monitored.

It was developed first from an anti-fungal compound that was shown to have these properties. The scientist who discovered it won a Nobel Prize. We valued it because it allowed very traumatized children to tolerate situations they found far too frightening and disorganizing.

In more recent times it is used for stagefright, agoraphobia, and such things. The above study sees it as a treatment for PTSD per se. That is what we used it for, and lo and behold, Harvard is catching up, some twenty years later. (link)

(more soon)

Posting Slowdown?

It is the last week of the school year...which means I have no idea how busy I am. I will be posting as much as I can. Every day, one item, at least.

A stroke, inside out...

(from Sunday's Times) As a Harvard-trained neuroanatomist, Jill Bolte Taylor has always known more about brains than most people. But when a brain hemorrhage triggered her own stroke, she suddenly had a front-row seat on the deterioration of the brain.

Dr. Taylor recounts the details of her stroke and the amazing insights she gained from it in a riveting 18-minute video of her speech at the Technology, Entertainment, Design Conference in Monterey, Calif., last month. Her fascinating lecture includes a detailed explanation of the differences between the left and right sides of the brain, complete with an incredibly cool prop — a real human brain.

On a December morning in 1996, Dr. Taylor woke up with searing pain behind her left eye, the beginnings of a hemorrhagic stroke. As the left side of her brain shut down, she began to feel disconnected from her body and entered an almost-euphoric like state. It took her a while to make sense of the experience, but as her right arm became paralyzed, it dawned on her that she was having a stroke.

“How many brain scientists have the opportunity to study their own brain from the inside out?,'’ she said. “In the course of four hours, I watched my brain completely deteriorate in its ability to process all information. On the morning of the hemorrhage, I could not walk, talk, read, write or recall any of my life.'’

Her account of the experience of stroke is vivid, and at one point, she recalled, she felt like someone had taken a remote control and hit the mute button. “I was shocked to find myself inside a silent mind,'’ she said.

What is so surprising about Dr. Taylor’s story is that she experienced a sort of euphoria as she was left with only right-brain functions. She lost her sense of self, but she also shed the stress of her life and, as she puts it, “37 years of emotional baggage.'’

“Imagine what it would be like to be totally disconnected from your brain chatter,'’ she said. “I felt a sense of peacefulness.'’

Dr. Taylor’s lecture is challenging and thought-provoking, and I’d encourage you to take the time to watch it in its entirety. It took Dr. Taylor eight years to recover from the stroke, but she said she was motivated by a desire to share her experience of stroke and recovery, particularly her increased awareness of the right side of her brain. “I realized what a tremendous gift this experience could be, what a stroke of insight this could be to how we live our lives, and it motivated me to recover,'’ she said.

To learn more about Dr. Taylor, visit her Web site.

The Placebo

In a dry, but interesting reframing of the role of placebo in healing and in research from the Journal of the Royal Society of Medicine the authors assert that the placebo effect can be observed independently of a doctor's direct efforts. Placebo regimens are used in a couple of ways. In one a relatively neutral agent is used to provoke the patient into self-healing. It happens all the time. Doctors have even begun proscribing placebo for parents to use with children.
In another, placebos are used in randomized, double-blind trials (researcher and subject are unaware of which is the drug and which is the placebo). If 40% of group A improves on the drug and 30% of group B improves on the placebo, the effectiveness of the drug is considered to be 10%.
This is a big assumption, but there it is. In psychiatric drug trials, for instance, drug companies use a "placebo washout" to ensure that their drug fares better than placebo. It goes like this: a group of 100 join the trial, say they all suffer from significant anxiety problems. All are given a placebo. 40 get better. Those 40 are removed from the trial. 60 remain. The 60 are divided into two groups, A and B. One is given the drug, one is given placebo. If the drug group fares better that the placebo group the findings are reported as evidence of drug effectiveness (over placebo).
But of course, a huge chunk of people were removed to try to ensure exactly that outcome.
Nevertheless, this is standard practice.

The assumption is that the placebo is "noise" in the study. The authors suggest that not only is the placebo a potentially powerful agent for healing, but that the healing is not just a response to the clinician's care and attention.

The idea is that our bodies are deeply conditioned to healing interventions. For instance, heroin addicts have been noted to get withdrawal relief merely by injecting water into their veins. KNOWINGLY. Deception is not necessary to evoke a healing effect.

The reframing is "Contextual Healing", that the whole context of providing care provides opportunity for healing- from the mechanics of delivery, to clinician's care, to the drug agents themselves.

Some part of each of us is fundamentally healthy. We respond to healing in a multitude of ways.