How are Iraq and Afghanistan war veterans dying? Is there an epidemic of premature deaths, relative to their civilian counterparts, among the still relatively young men and women who saw combat deployment over the past decade? In an era of big headlines and the twenty-four hour news cycle, the average American citizen might justifiably presume that suicide is the leading cause of death among veterans of the Iraq and Afghanistan wars. We have all heard variations on these startling pronouncements: “More Iraq veterans have died by suicide than were killed in combat operations!” “One Iraq war veteran commits suicide every hour!”

Despite the media-driven answers one might think exist to the question that heads this post, the factual truth is no one really knows. The reason we do not know is that all-cause mortality among these veterans has not been carefully studied or tracked.

Texas-based study

A few months ago, the Austin American-Statesman published results of an examination of all-cause mortality among Iraq and Afghanistan war veterans who were listed as VA beneficiaries in Texas. Their results, published in a three-part series September 30, October 1 and 2, 2012, indicated that drug overdoses or toxic combinations of drugs (mostly prescription medications, such as painkillers like Oxycontin) accounted for approximately as many deaths as those that were clearly suicide. Of the 266 deaths with known causes in this study, 16.9 percent were ruled as suicides, 18.8 percent were as a result of motor vehicle accidents and 17.7 percent were drug-related deaths.

This is important information, and yet the Statesman study raises more questions than it answers. This is true for several reasons:

1. We do not have a clear understanding of the number of veterans who were VA beneficiaries in each year of the study. Without this denominator, it is impossible to calculate rates of the various causes of death.
2. Causes of death were only obtained in about two-thirds of the cases, leaving us with many individual mysteries about how and why these veterans died.
3. We have no contextual information to compare these data to. How do these Texas veterans’ deaths compare to an age-gender-race matched comparison group of non-veterans from Texas? 

What remains are some very interesting raw numbers, but we still do not have all the answers needed to guide prevention efforts.

Now what?

So, where does that leave us?  As we wrote in a blog post for the Huffington Post recently, there is good reason to be more concerned about prescription medication deaths among veterans. This is an issue that has received only scant attention. Few people involved in the national dialogue on combat veterans’ issues are talking about this or seem to recognize the grave threat it poses to the health and well being of our active-duty troops and more than two million veterans. This is despite the fact that prescription drug use of opioids rose dramatically over the past half-generation, and is now America’s deadliest drug epidemic. The CDC reports that more than 15,000 people in the U.S. die each year from overdoses or toxic combinations of prescription medication painkillers. This is more than a 300 percent increase since 2000, and the numbers continue to rise. In fact, more people die from abuse of prescription painkillers than from cocaine, heroin and all other illegal drugs combined. Three years ago opioid-related deaths surpassed traffic accidents to become the leading cause of accidental death in America.

Young veterans, with their catalogue of blast injuries, headaches and chronic back/joint pain, may be especially vulnerable to the dangers of opioid prescriptions. Even for those who do not overdose, opioids change the brain, rewiring neural circuitry that leads to a host of other ripple effects – physical, emotional and social. Of course, we also should be concerned about the tragedy of suicide among our veterans. Especially since suicide has risen dramatically over the past decade among active-duty military personnel and since suicide may be more prevalent than it was historically when compared to wars of the past, such as the U.S. Civil War (1861-1865).

In an encouraging follow-up story, the Statesmen reported that since their study ran – and possibly because of their effort – the VA has announced plans to conduct a large national study of all-cause mortality among veterans of Iraq and Afghanistan. This is good news, as it will shed light on veteran suicides and drug overdoses, and will help answer the question posed in this post’s headline. As a nation we have a duty to help veterans live long and productive lives. An important step toward realizing this is to ensure that we fully understand all causes of veterans’ deaths, especially premature deaths. It is encouraging that perhaps we are about to begin a national effort to do this.

Mexican heads macheted off at the neck and dopers lying around stoned out of their minds. What’s the connection? If you’re an American and smoke dope, you’re contributing to the current violence in Mexico. You’re the demand, they’re the supply and legalizing pot won’t change that. The cartels will always come up with an attractive pot blend priced lower than Uncle Sam’s –­ a competition that would be ludicrous to initiate but oh how branding consultants would love it. We’ll see how it plays out in Colorado and Washington state.

If you don’t care about people you don’t know getting whacked by the cartels, how about this: The dope you smoke is making you stupid, stupid enough for people to notice.

Scholarly longitudinal research

On August 28, 2012, BBC News, among other outlets, reported the results of a long-term study of 1,000 adolescents who smoked pot. The Dunedin study revealed that young people suffered cognitive impairments far beyond their youth:

Having taken into account other factors such as alcohol or tobacco dependency or other drug use, as well the number of years spent in education, they found that those who persistently used cannabis – smoking it at least four times a week year after year through their teens, 20s and, in some cases, their 30s – suffered a decline in their IQ.

IQ declines, by the way, are irreversible. The Dunedin Multidisciplinary Health and Development Study was only one study, but it had an unprecedented 96 percent response rate. Participants were honest about their drug use because they had spent so much time with the researchers: The IQ testing and interviews lasted from 1972 to 2012 and included questions about mental health and psychosocial functioning.

Test yourself

You think you’re OK because you weren’t consistently smoking cannabis as a teen? Or maybe you didn’t take toking up until college when your brain was all but through with its critical development stage? Try recording yourself next time you’re stoned. (Voice is fine, videotape is better.) You might sound like someone who’s lost IQ points, despite the fact you consider yourself an ambitious, well-paid success in this world. Yeah, the stupid effects of weed are temporary but why bother? As an educated professional, wouldn’t you be curious to see if you can do without dope for two months as an experiment?

Would you not discover the unadulterated, real you?

The field of psychotherapy suffers from acronymania: a proliferating plague of acronyms. Your psychotherapy brand will not be taken seriously if you don’t have a good acronym for it, preferably three letters, although you can get by with four or two. A short list: CBT, DBT, TFP, DIT, CPP, TPP, SIT, ERP, IPT, PCT, CFP, EFT, MBT, RLX, EMDR, ADEP and PE. Ideally, your therapy will qualify as an EBT or EST (evidence-based or empirically-supported treatment), that is, a treatment of experimentally-proven effectiveness that comes with a manual instructing the therapist on how it’s to be conducted.

More acronyms, please

Of course, we also have acronyms for psychiatric conditions: MDD, OCD, PTSD, BPD and so on. The crowning glory is having an EST for a particular condition: CBT for MDD, ERP for OCD, PE for PTSD and MBT for BPD (translation: cognitive-behavior therapy for major depressive disorder, exposure and response prevention for obsessive-compulsive disorder, prolonged exposure for posttraumatic stress disorder and mentalization-based treatment for borderline personality disorder, respectively).

We are truly blessed that clinician-researchers have developed all these ESTs for various psychiatric disorders. We need these specialized treatments for specific disorders and symptoms. Yet there are two problems with this state of affairs. First, to be fully competent in treating a range of psychiatric disorders, the therapist would need to learn 150+ treatment manuals—a daunting task. Second, many patients who seek treatment have a number of different disorders and problems at the same time (e.g., depression, anxiety, alcohol abuse, an eating disorder and personality disturbance).

Do we send such patients to several psychotherapists, as we might send patients to several medical specialists? Does the same psychotherapist administer several treatments sequentially, one after the other, or even concurrently?

Common factors

The problem I am addressing is not unique to psychiatry or even general medicine. We live in a world of increasing specialization such that individuals can hardly even keep up with the knowledge in their own field of endeavor. In the field of psychotherapy, there has been, in response to ever-increasing specialization, a countervailing movement for decades: the emphasis on “common factors” that account for the effectiveness of the therapy, regardless of the therapist’s specific technique or the brand name of the therapy. There is solid research support for this focus on common factors: it is extremely difficult to demonstrate that any good type of therapy is more effective than any other.

For example, we know that a positive therapeutic alliance—a trusting relationship in which the patient and therapist are working together toward common goals—is a major contributor to the effectiveness of therapy. Another important common factor is the therapist’s empathy. Recently, we have been advocating another common factor based on attachment theory and research: mentalizing, that is, an open-minded or mindful attentiveness to mental states such as thoughts, feelings and needs in oneself and others. It is a truism that psychotherapy requires interest in what is going on in the mind—and a meeting of minds. We use our colleague, Peter Fonagy’s, phrase for this process: holding mind in mind. We describe the ubiquitous role of mentalizing in relationships—including psychotherapy relationships—in our book, Mentalizing in Clinical Practice.

New psychotherapy brand

I am more concerned with common factors than specific techniques; I aspire to mentalize and help my patients to do so with me; and, not denying my competitive response to social pressure, I feel a need for a catchy acronym.

Hence, after more than four decades of practicing psychotherapy, I have decided on my own brand of psychotherapy: POT, Plain Old Therapy.

A patient once asked me at the beginning of our first session, “What kind of therapy do you practice? Talk Therapy?” I replied, “Yes, Talk Therapy, that’s what I do.” But I like POT better than TT.

To the extent that psychotherapists are returning to a common core of effective elements, the psychotherapy field might be going to POT. For many patients whose symptoms are multifaceted and rooted in problems with self and others, POT is in order. I acknowledge that POT is not optimal for treating patients with specific disorders for which effective specialized treatments are available. But even these specialized treatments, well delivered, must be laced with POT.

In his popular book, A Secure Base, John Bowlby, the psychiatrist and psychoanalyst who pioneered attachment theory, stated that the psychotherapist’s role is

“to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.”

In a trauma education group, I once remarked, “the mind can be a scary place.” A young woman in the group spontaneously replied, “Yes—and you wouldn’t want to go in there alone!” She thus epitomized Bowlby, and I have never heard such a trenchant characterization of psychotherapy since. This is POT, as I endeavor to practice it.

Coping with Depression, one of many books written by Jon G. Allen, PhD

I have found two basic ideas to be helpful in understanding depression: stress pileup and catch-22. We know that episodes of major depression are preceded by stressful events, and these events have two main themes: loss and failure. Loss of a key relationship through death, divorce or a break-up is a common precipitant of depression. A feeling of failure could be associated with not meeting your aspirations or others’ expectations at work or in school—or with relationship problems that also involve loss.

Often, depression is preceded by a cascading pileup of stress: problems at work lead to overuse of alcohol, which further impairs work performance; drinking to cope leads to marital conflict, which further fuels alcohol use; marital conflict is stressful for children, who then have more difficulty in school—such scenarios are innumerable.

All the things you must do to recover from depression are made difficult by the symptoms of depression.

Being vulnerable

Although depression is commonly preceded by stress, many people manage a pileup of stress without becoming depressed. Why do some and not others succumb? One reason is genetic vulnerability to becoming depressed in the face of stress. In addition, general medical conditions and physical ill health can contribute to depression.

Yet another reason for vulnerability: a history of stress pileup over a person’s lifetime. Childhood trauma, such as loss, abuse and neglect—combined with genetic vulnerability—can contribute to risk for depression in adulthood. Stress and episodes of depression in adolescence also add to risk for later depression. And, as in the example given earlier, substance abuse is a catalyst for depression: if you’re headed into depression, substance abuse can speed up the process and hinder recovery.

Depression’s impact

Depression notoriously saps energy and impairs concentration and complex problem-solving ability. Thus, heading into depression, you are liable to struggle harder to stay afloat, for example, in managing demanding jobs and household responsibilities, including caring for children or aging parents. Effort increases while energy decreases. At some point, you run out of energy entirely and “crash” into severe depression. It’s as if your mind wants to keep going but your body declares, “I quit.” At the extreme, you can become bedridden.

Adding insult to injury and contributing further to the pileup is the fact that many people feel ashamed of being depressed and withdraw from relationships as a result. Because social isolation is a major contributor to depression, more stress pileup ensues. Another potential blow: the prospect of stigma can interfere with seeking professional help.

The catch-22

Paradoxically, the process of recovering from depression also is stressful in that it’s extremely challenging. I attribute this to a catch-22: all the things you must do to recover from depression are made difficult by the symptoms of depression: you should sleep well, eat well, be active, engage in pleasurable activities, think realistically, stay engaged with persons who can provide support and maintain hope.

Now consider the symptoms of depression: insomnia, poor appetite, lethargy, diminished capacity for pleasure, negative thinking, social withdrawal and hopelessness. Recovery is the norm, but the catch-22s often make this process of recovery slow—several months to recover fully from an episode of major depression is not unusual. (I talk a lot about the catch-22s of depression in my book Coping with Depression in case you’re interested in learning more about them.)

Tips on recovery

Here are some key points for recovering from depression and preventing further episodes:

1. See if you can find a way to get out of the maelstrom of stress pileup to take stock of your situation, respecting the power of the stresses without minimizing them. Psychotherapy can be helpful in such stock-taking; sometimes patients need the asylum provided by hospitalization to get the needed respite and distance from the stressful situation.
2. At least in the short run, do everything humanly possible to minimize stress. This is not easy: you can’t give up your children or quit your job and go to the Bahamas. Yet you might find ways to cut back some. Saying “no” is not easy but can be helpful. Ditto for seeking help.
3. Take stress seriously and develop methods of coping more effectively. In his masterful book, The End of Stress as We Know It, stress researcher Bruce McEwen asserted that everything we know about managing stress our grandmothers could have told us. But now we have the scientific evidence to back up grandmother’s wisdom. Sleep, diet, exercise, relaxation, pleasurable activities—these are the mainstays of stress management. Yet we must be mindful of the catch-22s.
4. Be patient with yourself regarding any difficulty you may experience in recovering from depression. Patients who have recovered refer to the “baby steps” that got them there. Catch-22: being patient with yourself can be difficult because depression spawns self-criticism.
5. Make every effort to stay connected: the mere presence of another person can ameliorate stress, and the presence of a trusted companion with whom you have an emotional bond is the most potent antidote to stress known to man (and to many other mammals).
6. A caution: It is little wonder that depressed persons seek potent chemical solutions. Alcohol, for example, relieves anxiety and produces pleasure—all too temporarily. In the long run, as stated earlier, substance abuse catalyzes and prolongs episodes of depression. The worst time to drink or do drugs is when you are doing so to manage psychiatric symptoms of any sort.

There is one major basis for hope: the vast majority of depressed persons recover, albeit slowly. And to drive home the importance of others in a person’s recovery,  I conclude with this anecdote: when I made the point in an educational group that it is difficult but not impossible to recover from depression, a patient rightly protested: “Doc, I can tell you that it was impossible for me to recover on my own.”