June 2015 Philadelphia Chapter of Pax Christi U.S.A.

The Solution is more than Medical

Colleagues ask me what I do. When I answer they frequently respond by saying, “See a lot of PSTD, I guess.” “Well, yes, but many service members suffer from ‘plain old depression,’” I respond. These individuals often feel profoundly lonely in a crowd and utterly helpless and hopeless. Their disorders differ by duration and timing of the symptoms and also their cause.

The incidence of depression in the world has increased substantially each decade in the past one hundred years. Epidemiologists speculate the cause. A November 2013 article in the Journal PLOS Medicine (Public Library of Science, a journal of peer-reviewed, open-access research articles) reported a worldwide map of depression that showed the highest incidence of reported depression in the world was in Afghanistan, the Palestinian Territories, North Africa as well as Eritrea and Rwanda. It does not take much imagination to realize what these places have in common - war and a lot of combat.

A soldier who witnesses many traumatized and dead bodies can experience depression. When soldiers regret what they have seen and done, even though they signed up to do it, that too can cause depression. Having trouble controlling your anger until it becomes overwhelming can also be a factor. Killing someone in the heat of battle, no matter how justified in the moment, can be experienced quite differently by the soldier when back home in the United States in the “comfort” of one’s family.

Most experience the common symptoms in depression - problems with mood; feeling down, up and down or just empty. Many suffer difficulty falling asleep or staying asleep or waking up too early. There may be problems with appetite or weight. Often individuals have somatic complaints, pain or dysfunction in one’s body. Somatic symptoms are more difficult to treat but the pharmaceutical industry created one drug specifically designed for somatic symptoms as well as created drugs for most of the other symptoms. There is always “talking.” Good psychotherapy may work as well as the drugs.

The one symptom that is more difficult is anhedonia: NO JOY IN LIFE. In my private practice of forty years in psychiatry I have seen people complaining of mostly all the symptoms mentioned above. Not often do I see someone who experiences no pleasure in living.

Recently I was confronted with this problem more forcefully than ever. A young female medic appeared for an appointment. Deployed three times, her depression began after the second deployment. Initially it went away slowly. After the third deployment the depression did not leave her. She had tried a number of antidepressants without success. It was not immediately clear if she self prescribed or she persuaded someone else to prescribe for her. Currently, she was on an appropriate but insufficient amount of a medication and said, “I have anhedonia.” I guess she wanted to sound rather professional, using a technical term, rather than seem to be a

suffering patient who had no joy in her life. She wanted a medication to solve this problem and had a list of medication possibilities.

For the past one and one-half years she thought daily of shooting herself. “Don’t worry,” she said, “If I decide to kill myself there is nothing you can do to stop me.” And then she cited all the ways she could obtain a gun and ammunition in this state or another. Her intentions were believable and serious.

Needing to get more information I asked a lot of questions. Her appetite and weight were fine. She could fall asleep for three - five hours and felt rested. She had adequate energy working long hours taking care of others. But she was clearly not the person she had been before her deployments. There was nothing in her life from which she gathered either satisfaction or enjoyment. She exercised but got no satisfaction from it. She hiked but no longer enjoyed being outdoors. Her family life was stable but emotionally distant. The last thing she had enjoyed was her deployment in which she worked with a very sophisticated medical team taking care of wounded and dying soldiers. She had a list of reasons: “I saw the best and the worst. I would return to work with those soldiers at a moment’s notice. I felt more connected to people than ever in my life. The quality of the work was exceptional. It was an expensively satisfying experience because it came at a great emotional price.” “It was not free,” she surmised.

I asked if she had talked to anyone else about her depression. “Yes,” she said, “I went to my commander.” “And?” I asked. “He told me ‘to get over it or get out of the Army.’” Stigma persists. She followed with, “I currently work as a medic in the most toxic environment imaginable, much worse than being deployed.” “How about your clergy?” I asked. She had a number of meetings with the Chaplin but felt he listened without really trying to understand.

Speaking as if I had not heard she said, “I did not consent to being born.” I thought it was one of the most astonishing statements a patient ever uttered. Was she saying, “I am alive against my own wishes? I did not want to be born. Life is not a gift.”

Had she no spiritual life? Did Pentecost make no sense? Where was her faith? Did she not accept God’s acceptance of her? Clearly she was authorizing her right to take her own life.

That astonishing comment coupled with “deployment comes at a price” led me to say “what makes you think your problem is medical? I think it might be more a moral one.” She had wondered the same thing.

“Why did you survive and so many others did not,” I asked. “I did not make any mistakes,” she responded. Is that what life is all about – not a gift but rather not making any mistakes?

We have different perspectives! But she is down a foxhole into which I am having a hard time reaching her. “What if I do not make another appointment?” she said. I thought the moral rather than medical approach was

pertinent and I said “I will come after you.” She deserves no less.

Ted Beal

Ted Beal, MD, a psychiatrist with the Department of the Army is also a member of the Georgetown Medical School faculty.