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Hippocrates is quoted as saying, “As to diseases, make a habit of 2 things—to help, or at least to do no harm.” In this issue of 

, we aim to help you do just that. Our coverage of the Annual 

 brings you the highlights and clinical pearls to help you better understand psychiatric illnesses and develop effective treatments for your patients. From the psychopharmacological wisdom of 

, our Educator of the Year, to guidance in caring for members of special populations—and even yourself—the esteemed faculty shared their tips for providing top quality care.

That theme resonates in this issue, as experts share cautions and concerns to prevent negative outcomes. For example, Steve Adelman, MD, shares his thoughts on prescribing caution in the case of benzodiazepines. According to the Centers for Disease Control and Prevention, there were almost 70,000 deaths attributable to opioids in 2020. Adelman further notes that concurrent use of benzodiazepine and opioids may occur in as many as 50% of opioid overdose deaths. In exploring the relationship between benzodiazepines and opioid use, he shares his concern and cautions for prescribing this class of medication.

Similarly, caution may be warranted in some cases when prescribing other psychotropic medications. Because some agents may trigger torsades de pointes, Margo C. Funk, MD, MA, and Junyang Lou, MD, PhD, share tips for understanding the 

. With this knowledge and guidance, you will be better prepared to identify potential pitfalls and prevent problems.

Care, concern, and cautions are also discussed throughout our Geriatric Psychiatry Special Report. Chaired by Rajesh Tampi, MD, MS, DFAPA, the section discusses issues in sleep, posttraumatic stress disorder, and issues surrounding COVID-19. As the US population ages, it becomes more important to be aware of the unique concerns impacting older adults, and this Special Report aims to support those endeavors.

From cover to cover, we hope this issue of 

 provides you with the tools, tips, and insights to follow in Hippocrates’ footsteps and help you help patients. ❒

This issue highlights the care, concern, and cautions in providing effective and thoughtful treatment to patients. 

Care, Concern, and Cautions

affects individuals of all ages with and without concomitant psychiatric disorders. To help foster recognition, Narmada Neerja Bhimanadham, MD, and Ornela Ali, MD, from the department of psychiatry at Bergen New Bridge Medical Center, in Paramus, New Jersey, shared a poster presentation on somatic symptom disorder at the 2021 NEI Congress.

Somatic symptom disorder is characterized by various bodily complaints that are not associated with organic changes and cannot be attributed to a disease. Although stressful life events (eg, loss of a loved one, children leaving home, financial hardships) often precipitate symptom onset, cytokines such as interferon, tumor necrosis factor, and cerebral asymmetry may also play a role, noted Bhimanadham and Ali. They reported prevalence of somatic symptom disorder tends to decrease after age 65 years, with rates range from 11% to 21% in younger patients, 10% to 20% in middle-aged patients, and 1.5% to 13% in older patients.

To illustrate the complexity of the disorder, Bhimanadham and Ali shared the case of a man aged 62 years with a history of anxiety and unspecified depression who voluntarily presented to the emergency department.

Upon presentation, the patient complained of generalized body aches, burning sensation, numbness of the forehead and face, all of which he noted began 2 years prior and after he took an herbal supplement for osteoarthritis. Based on research on the internet, the patient further believed he developed lead poisoning as a result. The patient appeared anxious, and he demanded that staff admit him and perform a number of diagnostic tests. 

Results of basic tests found complete blood count, serum chemistry, and bronchoalveolar lavage within normal limits. Urinalysis analysis and SARS-CoV-2 test were also negative. After further investigation, it was learned that the patient received a diagnosis of somatoform disorder in 2013 and was hospitalized in January 2021 with similar complaints. At that time, he underwent numerous diagnostic tests, including EEG, electromyography, spinal tap, CT of his head, and 25 MRIs of the brain, all of which were nonsignificant.

During the evaluation, the patient noted his daughter had moved out of the house, around the same time the symptoms first appeared. His demeanor changed when discussing his daughter, with sad affect noted.

In terms of treatment, trials of venlafaxine, lurasidone, paliperidone, duloxetine, mirtazapine, clomipramine, quetiapine, risperidone, and fluvoxamine were used. Unfortunately, there were issues with adherence, so the efficacy of the various regimens was unknown. However, the patient’s condition stabilized, and he was discharged after a thorough evaluation.

“Phase of life problems could also contribute to somatic symptom disorder due to lack of coping strategies to manage stress, life changing situations, or to face the expected physiological changes and cognitive decline that are part of normal aging process,” Ali said in the poster presentation. She added, “We know that primary care physicians, psychiatrists, and neurologists encounter most of the cases, where 20% to 60% of outpatient visits constitute of medically unexplained symptoms.”

“The concept of mind-body dualism might pose a challenge in early identification of the condition and subsequently lead to frequent hospital visits, numerous diagnostic tests, and an overall increase in health care costs and patient dissatisfaction,” Ali reported. With that in mind, Ali emphasized the importance of inquiring about risk factors such as social and psychological stressors to assist in identifying somatic symptom disorder. She also suggested the use of PHQ-15 in clinical practice, especially in primary care settings, as an effective screening tool.

“Management should be focused on establishing a strong patient provider relationship, combining psychotherapy and pharmacotherapy to improve outcomes and, ultimately, patient's quality of life,” she concluded.

Exploring Somatic Symptom Disorder: A Case Report

Parul Kumar, MD, and colleagues from Westchester Medical Center, 

, Department of Psychiatry, reported on an unusual encounter as part of the 2021 Neuroscience Education Institute Poster Presentation. The patient, aged 38, was a White female with a history of schizoaffective disorder. She presented to the emergency department with reports of racing thoughts, distractibility, increased energy, decreased need for sleep, and hyper-talkativeness.

The patient reported delusions of her father invisibly raping her. She also reported hypoguesia and 

 1-2 days prior to her visit to the emergency department, but now was hallucinating smells of blood and flesh. She denied head trauma, seizures, as well as previous emotional, physical, and sexual trauma. The patient noted a remote history of migraines.

Neurological examination was within normal limits, as were brain computed tomography, chest X-ray, and various laboratory studies. However, the patient tested positive for SARS-CoV-2.

Following admission and treatment for 2 days that included aripiprazole, haloperidol, topiramate, and fluoxetine, the patient reported resolution of the hallucinations and was discharged to follow-up outpatient care.

Research has indicated that patients with schizophrenia have an increased risk for acquiring COVID-19, with an adjusted odds ratio of 7.34,

 along with increased risk for hospitalization (27.4% vs 18.6%) and mortality (8.5% vs 4.7%) compared with individuals with no psychiatric disorders, respectively. Kumar et al noted the olfactory symptoms were the only presenting symptoms associated with COVID-19 in their patient. Thus, they recommended testing for SARS-CoV-2 in patients with psychosis or other psychiatric illness who present with olfactory symptoms as part of the differential diagnosis.

Increased risk of COVID -19 infection and mortality in people with mental

disorders: analysis from electronic health records in the United States

This case presented as part of the Poster Presentations at the 2021 NEI Congress is a good reminder of the importance of taking a thorough history.   

Case Report Poster: A Smelly Situation 

sorority and fraternity gatherings in nasal cavities

Seasons of isolation bemoan with libations

and carnage lies listless unmasked with sorrow

COVID-land celebrates with spike protein confetti

red and blue irrelevant for host transmisison

Moderna, Pfizer, and J&J scholastic squad

is an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine, Greenville. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

A poet's reflections on COVID-land's relentlessness grip on society...

Variant Party

 Tales From the Clinic: The Art of Psychiatry, 

we follow a psycho-oncology case of lung cancer, compounded by depressive and anxiety symptoms. Faced with fear of death, individuals go through stages of grief, as described by Elisabeth Kübler-Ross, MD, in 1969. This discussion highlights the psychotherapeutic, pharmacological, and diagnostic considerations of this comorbidity.

“Mr Arnold” is a 67-year-old retired teacher with no past psychiatric or medical history. He was referred to a psychiatry clinic for sadness and anxiety shortly after being diagnosed with metastatic adenocarcinoma of the lower lobe of the left lung. The devastating diagnosis caught Mr Arnold off guard just months into his retirement, as the only symptoms he experienced were cough and progressive fatigue. Besides these complaints, he had no past medical issues, always stayed committed to a healthy lifestyle, and underwent regular screenings and physical exams. Mr Arnold did not have any history of tobacco smoking, alcohol drinking, or any other substance use. He felt numb when he first heard the diagnosis because he was overwhelmed with a range of strong emotions: disbelief, anger, fear, anxiety, and sadness. Mr Arnold’s retirement plan now had to be put on hold so he could focus on cancer treatment. He had already suffered tremendous grief a few years earlier after the loss of his wife of 30 years to cancer. This time, he was traumatized by 

During the initial visit to the psychiatry clinic, he complained predominantly of fear of death, hopelessness, insomnia, social isolation, anger, guilt, and worry for his girlfriend if the treatment fails: “What will she do without me? Who will take care of her after I die?” Mirtazapine was started to target depression, anxiety, poor sleep, and low appetite; however, Mr Arnold found the medication too sedating. Sertraline was subsequently started and was much more tolerable and helpful with alleviation of anxiety and depression.

He was started on chemotherapy and radiation treatment soon after diagnosis. During the early stages of 

, he had difficulty coping with the treatment burden and reported worsening symptoms of anxiety. He was affected not only by the cancer diagnosis, but also by the treatment and its side effects, which worsened his depression and anxiety, lowered his quality of life, and exacerbated his loneliness and social isolation. Besides pharmacological intervention for depression and anxiety, he was concurrently seen by a psychotherapist to work on relaxation techniques, deep breathing exercises, and cognitive behavioral therapy. After persevering through almost 2 years of cancer treatment, Mr Arnold felt extremely relieved when the PET scan showed no evidence of active disease. Subsequent CT scans were negative as well. Mr Arnold later continued maintenance oral chemotherapy. While he felt relieved and hopeful for the future, a part of him still felt anxious that the cancer might recur.

Lung cancer is second only to breast cancer in prevalence. Older adults with lung cancer face a range of challenging issues, including demoralization, 

, treatment distress, anxiety, and depression. Some issues relate to loss of control and dignity, whereas others stem from problems related to quality of life. Smokers, or individuals who feel their cancer stemmed from negative behaviors of their own doing, often experience shame and worse depression.

 In therapy, fear of mortality and psychosocial decline need to be addressed. Stages of grief must also be highlighted and worked through, although stages do not have to occur in clean, predictable order.

For Mr Arnold, it was hard to imagine a worse time for him to receive the news of this devastating diagnosis because, after decades of working hard, he had been looking forward to spending the post-retirement years traveling. Like other patients, Mr Arnold found himself in shock (the denial/shock stages of grief). He now had to face the dreadful transition from anticipating years with joyful activities to navigating the uncharted waters of a deadly illness and difficult treatment. Mr Arnold experienced demoralization similar to Erik Erikson’s concept of despair in the final stage of one’s life, where he partially felt regret over the life he had lived and the feeling of 

Compared to other malignancies, lung cancer is associated with a higher rate of mortality and symptom burden, which can cause serious psychological suffering. Facing a terminal illness, Mr Arnold felt devastated and in despair; he now believed he had only a slim chance of being able to do the meaningful things that he had worked and planned for all his life (ie, traveling around the world). Although he reflected on the life he had lived with pride, having raised 2 successful children, he felt regret for not doing enough of what he felt would have brought him happiness (the depression stage of grief). During the course of his cancer treatment, Mr Arnold constantly found himself in a tug of war between hope for a full recovery (so he could travel) and, in his words, “make peace” (achieving ego integrity, the bargaining stage of 

) with the life that he had led and the fear of death.

Reflecting on his life, Mr Arnold felt that being diagnosed with lung cancer was unfair for him since he never had medical problems and had been committed to a healthy lifestyle (the anger stage of grief). He never smoked tobacco, drank alcohol, or abused any substance. Like most lung cancer patients, Mr Arnold was diagnosed when the cancer was in the late stage because his early symptoms—dry cough and fatigue—were nonspecific and dismissed without further work-up. He also reported feeling guilty about the possibility of becoming a burden on his girlfriend, who herself had chronic conditions. 

 is key in improving outcome at this stage in treatment.

 In aging patients, this is a common concern that needs to be addressed in multimodal treatment planning, as there is increasing recognition that caregiver health and patient health are interdependent.

During his first visit with psychiatry, Mr Arnold reiterated tearfully that he had saved money all his life for retirement and planned to travel extensively in the last meaningful years of his life. The addition of psychotherapy was essential in guiding the patient through the stages of grief. Although lung cancer is the most frequently occurring cancer and the leading cause of cancer death in men,

 it is essential to help patients realize that many cancer occurrences do not lead to death (the acceptance stage of grief). He was psychologically tormented by the 

, especially in the aftermath of the diagnosis and early stages of treatment.

As the lung cancer treatment progressed, Mr Arnold started to worry more about his financial situation since his retirement savings were quickly depleted by medical bills. He felt resentful that a significant portion of his retirement savings was now drained, and he could not help his girlfriend. Alleviating the burden of treatment in this situation was integral to improving the patient’s anxiety and depression. Considerations for patients in this situation include 

 of disease/cancer staging, likelihood of poor prognosis, and uncertainty in treatment and outcome.

Screening for depression among patients with lung cancer can be tricky as multiple confounding factors present as neurovegetative symptoms, mostly related to the cancer and its treatment; for example, low energy, poor appetite, decreased motivation, loss of interest, and decreased concentration. Research has shown that the level of distress experienced by lung cancer patients is not correlated with the type or stage of cancer, but that individuals with 

 may have higher health resource utilization and worse outcomes.

The best management of lung cancer and treatment distress requires early and comprehensive care coordination involving a multidisciplinary team to address physical suffering, spiritual needs, psychosocial stressors, nutritional needs, and psychological suffering. The goal is to provide adequate control of physical symptoms, psychosocial support, and management of anxiety and depression.

Another benefit of this antidepressant, and the reason it was selected as first line, is that it alleviates gastrointestinal symptoms (nausea) induced by chemotherapy and poor sleep related to distress and anxiety.

 for depression; the medication was also helpful for anxiety. Another benefit of this antidepressant, and the reason it was selected as first line, is that it alleviates gastrointestinal symptoms (nausea) induced by chemotherapy and poor sleep related to distress and anxiety. Mr Arnold had a good response to mirtazapine; however, the sedation caused by its side effect was a major issue because he already struggled with fatigue and low energy. Sertraline was later started and proved to be a better choice for his depressive symptoms. However, in treating patients with cancer, drug interactions have to carefully considered because selective serotonin reuptake inhibitors are sometimes associated with increased cytotoxicity when combined with certain chemotherapy agents.

Because of fatigue, depression, and anxiety, Mr Arnold notably lost interest in his routine activities. For the treatment of fatigue, he needed only conservative care such as physical therapy and energy conservation; no pharmacological intervention was required. During the course of 

, it was important to focus on Mr Arnold’s mood improvement based on depression symptoms that are psychologically based, rather than neurovegetative ones that are related to lung cancer such as fatigue, pain, dyspnea, weakness, insomnia, and poor concentration. Distinguishing physical symptoms due to cancer treatment is essential in this patient group.

The depression symptoms that were considered markers of depression response include feeling hopeless/helpless or unmotivated, easy crying, irritability, self-blaming, social isolation, and mood/affect change. The patient’s quality of life and other meaningful elements of his life were also important to consider when following up on the treatment of depression and anxiety. Helping the patient’s mood serves a dual purpose, both as a success in mental health treatment and a way to improve the patient’s immune system and improve adherence to the lengthy cancer treatment program. 

When evaluating anxiety among patients with lung cancer, it is also important to distinguish physiologically based dyspnea and anxiety from a psychological state.

Mr Arnold’s anxiety could have started with a respiratory deficit, but it was later exacerbated by the fear of death, catastrophizing, as well as feeling hopeless and helpless. Besides the psychological trauma, going through 20 months of radiation and chemotherapy was an ordeal for Mr Arnold, as he struggled with poor quality of life due to severe pain induced by the treatment. Because pain is a multidimensional and complex experience, it was imperative to explore the psychospiritual dimension of his suffering during follow-up visits. Discussing his pain, fear, concern, loss of autonomy, and dignity helped relieve Mr Arnold’s distress. Fortunately, he was not reluctant to talk about these concerns.

With a good response to the cancer treatment, Mr Arnold’s grieving mostly resolved after successfully completing his treatment, with residual intermittent anxiety of disease recurrence.

is assistant professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Director of Community Psychiatry Clinics at the Harris Health System, Houston, Texas.

is Assistant Professor, Department of Psychiatry, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.

1. Siwik CJ, Phillips K, Zimmaro L, et al. 

Depressive symptoms among patients with lung cancer: elucidating the roles of shame, guilt, and self-compassion.

2. Ketcher D, Otto AK, Vadaparampil ST, et al. 

The psychosocial impact of spouse-caregiver chronic health conditions and personal history of cancer on well-being in patients with advanced cancer and their caregivers.

3. Bray F, Ferlay J, Soerjomataram I, et al. 

Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.

4. Sullivan DR, Ganzini L, Duckart JP, et al. 

Treatment receipt and outcomes among lung cancer patients with depression.

5. Ester M, Culos-Reed SN, Abdul-Razzak A, et al. 

Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer.

The selective serotonin reuptake inhibitors enhance the cytotoxicity of sorafenib in hepatocellular carcinoma cells.

Comorbid depression in surgical cancer patients associated with non-routine discharge and readmission.

A patient, faced with a lung cancer diagnosis and the fear of death, goes through the stages of grief. How can you as clinicians lead them through?

“I’m Not Ready to Die”


The importance of maternal mental health for fetal development has been the subject of 

 Researchers have also investigated the possibility that other perinatal illnesses, like viral or bacterial infections, could increase the risk of a child later developing psychiatric conditions such as schizophrenia.

Perinatal immunological diseases may have long-term effects, too, especially because the

 There is evidence that activation of the maternal immune system during pregnancy—whether by infection, chronic inflammation, or autoimmune disease—is associated with increased risk of neurodevelopmental disorders in the offspring.

 In the case of the latter, maternal autoantibodies may cross the placenta and alter fetal development through epigenetic changes, brain microglial cell activation, and modulation of synapses.

Previous studies have focused on the association between maternal autoimmune disease and autism spectrum disorders, whereas attention-deficit/hyperactivity disorder (ADHD) has been less studied. Only 1 

 examined the association between any maternal autoimmune disease and ADHD risk in children.

 A recent paper, however, set out to investigate the association between any (and specific) maternal autoimmune disease and ADHD in children, and to incorporate those results into a systematic review and meta-analysis on this topic.

Using the New South Wales (NSW) Perinatal Data Collection, Nielson and colleagues identified all women with full-term, singleton live births from July 2000 to December 2010. Birth data were linked to all hospital admissions for both mother and child, and pharmaceutical data for the child for treatment of ADHD through registers. A child was considered to have ADHD if they had a stimulant prescription for ADHD and/or a hospital diagnosis of ADHD. Children linked to a first ADHD event before age 3 years were excluded. Children were followed to death or at the end of follow-up in December 2014.

Maternal autoimmune disease was determined based on the mother’s hospitalization records. Children whose mother had at least 1 hospitalization for autoimmune disease were considered exposed. Exposed and nonexposed mothers were propensity matched based on age, country of birth, socioeconomic status, place of residency, parity, smoking during pregnancy, and mental health diagnosis. Cox proportional hazard models were used to examine the association of maternal autoimmune disease and ADHD, adjusting for child sex. Analyses were performed for any maternal autoimmune disease and individual conditions with at least 15 cases of ADHD among exposed children.

The authors also performed a systematic search of MEDLINE, Embase, and Web of Science to identify studies on the association between maternal autoimmune disease and ADHD. Studies were assessed for quality using the Newcastle-Ottawa Quality Assessment Scale. Meta-analyses of any (and specific) maternal autoimmune disease with ADHD in the offspring were performed by calculating random-effects pooled hazard ratios (HRs) and inverse-variance weighting.

In the NSW Perinatal Data Collection, 831,718 mothers and children were included, and 12,767 children (1.5%) were exposed to maternal autoimmune disease. Propensity score matching included a cohort of 12,610 exposed children and 50,440 controls. During follow-up, 1094 male (3.4%) and 332 female (1.1%) children were diagnosed with ADHD. After adjustment, any maternal autoimmune disease (HR, 1.30), type 1 diabetes mellitus (HR, 2.23), psoriasis (HR, 1.66), and rheumatic fever or carditis (HR, 1.75) were associated with increased risk of ADHD, and this association was not moderated by child sex (

). When considering mothers diagnosed before or within 180 days of birth (N = 9700), any maternal autoimmune disease (HR, 1.28) and type 1 diabetes mellitus (HR, 1.95) remained significantly associated with ADHD.

Five studies, including the present cohort, were included in the meta-analysis. Two studies estimated the association with any maternal autoimmune disease, and 11 specific conditions were investigated in 2 or more individual studies. In the meta-analyses, any maternal autoimmune disease (HR, 1.20), type 1 diabetes mellitus (HR, 1.53), hyperthyroidism (HR, 1.15), and psoriasis (HR, 1.31) were all associated with increased risk of ADHD.

The authors found an association between any maternal autoimmune disease, type 1 diabetes mellitus, and psoriasis in both the present study and meta-analysis, and an association with hyperthyroidism in the meta-analysis. They noted significant heterogeneity in findings across individual studies, and that nonimmune factors such as glycemic control (in type 1 diabetes) and endocrine aspects of hyperthyroidism may also contribute to associations with ADHD.

Strengths of the present study include the hybrid design, including a large population-based cohort and meta-analysis. Limitations include the lack of outpatient/primary care records for identifying maternal autoimmune disease, absence of data on the clinical status of the mother’s autoimmune disease and associated medications, and absence of data on nonstimulant ADHD medications and severity of ADHD.

Maternal autoimmune disease is associated with increased risk of ADHD in offspring, adding evidence that adverse maternal immune function during pregnancy may alter fetal neurodevelopment. Children of affected mothers may benefit from additional follow-up and support for developmental issues.

is a professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the editorial board and serves as the schizophrenia section chief for 

. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, the Brain and Behavior Research Foundation, and the Stanley Medical Research Institute.

1. Stein A, Pearson RM, Goodman SH, et al. 

Effects of perinatal mental disorders on the fetus and child.

Perinatal depression: implications for child mental health.

Maternal infection during pregnancy: increased risk of psychosis in offspring. 

Multifaceted interactions between adaptive immunity and the central nervous system. 

5. Knuesel I, Chicha L, Britschgi M, et al. 

Maternal immune activation and abnormal brain development across CNS disorders

Maternal immune activation: implications for neuropsychiatric disorders.

Maternal inflammation and neurodevelopmental programming: a review of preclinical outcomes and implications for translational psychiatry.

8. Rising Nielsen P, Eriksen Benros M, Dalsgaard S. 

Associations between autoimmune diseases and attention-deficit/hyperactivity disorder: a nationwide study.

9. Nielsen TC, Nassar N, Shand AW, et al. 

Association of maternal autoimmune disease with attention-deficit/hyperactivity disorder in children.

A new research study, based on over 800,000 mothers and children, tests the hypothesis. 

Could Childhood ADHD Have Its Roots in Perinatal Autoimmune Disorders?

A most pronounced characteristic of the cases seen early in their illness is the profusion with which new symptoms appear and disappear. As time goes on, without treatment, a more stabilized syndrome crystallizes.

Those who have worked with combat veterans know that they are a group of patients who require a special degree of honesty and compassion. According to the US Census Bureau, there are 18.0 million veterans living in the United States, 17% of whom are women.2 In addition, at any given day, 1.4 million men and women serve on active duty, along with 718,000 civilian personnel. Another 1.1 million Americans serve in the 

. It is estimated that 7% of the US population has military experience, which is 

. Among post-9/11 veterans, 43% have a service-connected disability,

 perhaps related to the fact so few in modern society (less than 1%) serve in the all-volunteer military, requiring citizen-soldiers and their families to carry the burden.

Unfortunately, institutions charged with caring for veterans are often unhelpful. The Veteran’s Administration’s (VA) lack of transparency is a significant handicap for veterans and family members seeking treatment and explanations for their mental illnesses. Researchers, clinicians, and journalists are unable to find answers to important questions about the impact of war on veterans and their families. How many post-9/11 veterans have been diagnosed and/or treated for posttraumatic stress disorder (PTSD)? How many veterans have been diagnosed with any other mental health-related condition?

It is hard to say. The VA’s annual reports on Analysis of VA Health Care Utilization Among Operation Enduring Freedom (OEF), Operational Iraqi Freedom (OIF), and Operation New Dan (OND) Veterans, stopped being publicly available in 2016. Nevertheless, based on 2015 data, we can say that over a million post-9/11 veterans are using VA healthcare, and mental disorders are prevalent in this population (

 Aside from the fact the data are outdated, the data also captures only those veterans going to the VA. The VA does not keep track of those seeking counseling from the 360 veteran centers across the country

; nor those who seek help through the private sector; nor the largest subset of veterans and military personnel who suffer silently. Of course, there are multiple millions of family members and caregivers within the military population, those critical for the military veteran, are not covered for any services.

Differences in the Treatment of Military Versus Non-Military Populations

Psychiatric Casualties: How and Why the Military Ignores the Full Cost of War

 we were asked to opine on what clinicians should know about treating military populations (

read an introduction to Dr Russell and Dr Figley’s book 

.). First and foremost, while it is true that war changes everyone, it is also a great disservice to assume that most or all citizen-soldiers who served in the military and/or deployed to war zones, are fatally damaged goods. Going to war often signifies both the best and worst of times for veterans. Military populations offer fertile ground for studies on resilience and posttraumatic growth (PTG) among specialties within the service branches.

On the flip side, it is important not to view evidence of resilience or PTG as indicating an absence of mental or physical health-related problems. Another potential mistake is to assume that current or former military personnel must have suffered war trauma, and that is the primary or sole issue that leads them to seek mental health services. In reality, the all-voluntary military faces a wide-range of potential traumatic stressors that are inherent occupational hazards including combat, training accidents, transportation accidents, terrorist attacks, military sexual trauma, victims of crime, natural disasters, humanitarian relief missions, peace-keeping missions, along with other common stressors in the civilian sector (ie, domestic violence, childhood abuse, motor vehicle accidents, betrayal trauma, racial trauma, etc). The wise clinician is alert to the fact that even if a service member is a combat veteran, their distress will likely be a combination of factors, not just a product of combat experiences.

Next, clinicians should be sensitive to a host of risk factors and trauma-related conditions that are not entirely unique to military populations. Like police, federal and state law enforcement, and related professions, combat veterans, may deal with 1) the psychological impact of killing or seeing others killed; 2) having been wounded-in-the line of duty; 3) exposure to the presence of traumatic grief and complicated bereavement of fellow officers or from the death of a loved one, including one’s combat buddies; 4) moral injury from participating or witnessing killings, legal or otherwise; 5) intense survivor guilt, 6) co-occurring traumatic brain injury or phantom limb pain in amputees; 7) posttraumatic anger and sense of betrayal trauma; 8) handling of human remains; 9) being a prisoner-of-war by war enemy, drug cartel, or a political party; 10) chronic pain conditions; 11) opioid misuse; and 12) secondary trauma and compassion fatigue.

Similarly, war has taught us time and again that human beings have manifest traumatic stress injuries. These injuries cross a spectrum of possible conditions, and that diagnosis like PTSD represents only a sliver of possible afflictions.

 Historically, war or other traumatic stress injuries are often divided into 2 broad classifications: 1) neuropsychiatric conditions that consists of the culturally accepted diagnostic labels of the day such as PTSD, mood disorders, anxiety disorders, psychotic disorders, impulse control disorders, substance use disorders, neurocognitive disorders, eating disorders, sexual disorders, personality disorders, and others, and 2) medically unexplained physical symptoms (MUPS) which include chronic fatigue, headaches, chronic pain, atypical cardiac symptoms, idiopathic seizures, autoimmune conditions, and others.

In the 21st century, the Department of Veterans Affairs 

, “such as chronic pain and fatigue, are common in the general and military veteran populations” and that “Chronic Fatigue Syndrome (CFS), Fibromyalgia (FM) and Irritable Bowel Syndrome (IBS) are among the most commonly diagnosed medically unexplained conditions.” However, there are far more potential MUPS diagnoses. These include noncardiac chest pain, pseudo seizures, multiple chemical sensitivity. Other studies on MUPS in the current war cohort indicate a high frequency of somatic complaints (

 Additionally, OEF/OIF veterans with and without a diagnosed mental health condition were treated in the VA for 222 types of MUPS.

As many clinicians are aware, somatic complaints are often considered a cultural idiom of distress.

 This is particularly true with military populations whereby stigma and fear of career reprisal can be so oppressive. The career-related stress makes it more likely to complain of headaches, back pain, and sleep problems as opposed to emotional symptoms.

Common Obstacles Military Populations Face to Receive Proper Mental Health Care

By far, the biggest obstacle that current and future military populations face regarding mental health care is the pattern of a sustained, self-inflicted mental health crises plaguing generations of Americans and society since World War I.

 These largely preventable catastrophes are caused primarily by chronic neglect and lack of accountability by the military and its government. Our most 

 noted 10 foundational lessons of war trauma identified by every military cohort since WWI. These lessons are essential to meeting the wartime mental health needs:

1) Recognizing that war inevitably causes large numbers of legitimate spectrum of war stress injury;

2) Adequate research, planning, and preparation are indispensable during both war and peace;

3) A large cadre of well-trained behavioral health specialists is compulsory during times of war and peace;

4) A holistic, public health approach to war stress injuries necessitates close collaboration with the private sector along with full mental health parity; 

5) Effective mental health services demand the empowered leadership of an independent, unified, organizational structure, a behavioral Health Corps, providing integrated, well-coordinated continuity of care equal to medical services;

6) Elimination of mental health stigma, barriers to care, and disparity should be a priority for leadership, as it directly affects individuals, families, and military readiness;

7) Ensure ready access to high-quality mental health services, including definitive care prior to military separation or discharge;

8) Families must receive adequate mental health and social support during and after military service;

9) Accurate, regular monitoring and reporting are crucial for timely, effective, management of mental health needs; and,

10) Robust dedicated mental health “lessons learned” policy and programs are integral to meeting present and future needs and prevent crises.

Despite being learned again at the end of every war, these lessons have not substantially improved veterans’ care. Perhaps the best evidence that little progress has been made comes from a Department of Defense (DOD) Task Force on Mental Health. In 2007 it identified

A single finding underpinning all others: The Military Health System lacks the fiscal resources and fully trained personal to fulfill its mission to support psychological health in PEACETIME or fulfill the enhanced requirements imposed during times of conflict (p. ES2).

The time for action is now. The human and financial costs of un-addressed problems will rise dramatically over time. Our nation learned this lesson, at a tragic cost, in the years following the Vietnam War. Fully investing in prevention, early intervention, and effective treatment are responsibilities incumbent upon us as we endeavor to fulfill our obligation to our military service members. 

This is a stirring plea for action, but the DOD offers no concrete proposal on where to start, or a sense of when we will know when it is enough. Without concrete proposals and ongoing commitment to investing in prevention, early intervention, and effective treatments, pleas like this one will remain empty.

Have we learned our lessons? More than 6 years into a shooting war, 99 urgent recommendations were made by the DOD task force, all reflecting neglect of the military’s well-documented centuries of “lessons learned.” The media, Congress, and Commander-in-Chiefs alike still have not met their responsibilities to investigate the reasons for gross negligence that harm countless members of the military population for this and future generations.

From our vantage point, the military is positioned in a unique leadership role within the broader society. It could inspire other leaders to step up, be accountable, and finally call for ending the stigma surrounding the mental health of its members. The question remains: why has the US government and its military refused to learn its war trauma lessons and what concrete actions are necessary to end the generational cycle of neglect and crises?

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service

is the Paul Henry Kurzweg, MD, Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

Those who served: America’s veterans from World War II to the War on Terror

. US Census Bureau, U.S. Department of Commerce. June 2020. Accessed September 15, 2021. 

Analysis of VA health care utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans, from 1st Qtr FY 2002 through 3rd Qtr FY 2015

 (October 1, 2001—June 30, 2015). June 2015. Accessed September 15, 2021. 

5. Russell MC, Figley CR. Generational wartime behavioral health crises: Part one of a preliminary analysis. 

6. Hoge CW, Terhakopian A, Castro CA, et al. 

Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.

Medical care needs of returning veterans with PTSD: their other burden.

Idioms of distress among trauma survivors: subtypes and clinical utility.

9. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: Part two of a preliminary analysis. 

10. Russell MC, Figley CR, Robertson KR. Investigating the psychiatric lessons of war and pattern of preventable wartime behavioral health crises

. Journal of Psychology and Behavioral Science

11. Arthur D, MacDermid S, Kiley K, et al. 

An achievable vision: report of the Department of Defense Task Force on Mental Health

. Department of Defense Task Force on Mental Health. Defense Health Board. June 2007. Accessed September 15, 2021. 

What psychiatric illnesses are most prevalent among veterans? And how can clinicians help them overcome obstacles to care?  

Treatment of Military Populations

The 9 months of pregnancy evoke a multitude of emotions for the mother carrying the "angelic parasite". Expectant mothers are mindful that morning sickness is quite common, but it does not deter them from keeping their eye on the prize. However, intractable vomiting during pregnancy, also known as 

(HG) is a condition that can have deleterious psychological and physiological effects in the form of depression, anxiety, significant weight loss (>5% of original body weight), and dehydration.

I have witnessed firsthand the impact HG can have on a mother’s well-being. My wife, Jennifer, experienced this condition all throughout her pregnancy. As a spouse, I attempted to comfort her as best I could but, at times, felt helpless. During the pregnancy she lost more than 30 pounds, and she required several hospitalizations. It was difficult, at moments, to find any silver linings that would help alleviate fears we had about her quality of life and the angelic parasite in her womb. Thankfully, with the help of a multidisciplinary medical team and a support system consisting of family and friends, my wife’s health improved. The ability to take a shower, brush her teeth, and enjoy a sip of water was rejuvenating.

Our daughter, Claire, now 2.5 years old, was born without any complications. She is the blessing that keeps on giving. It is important to remember that not everyone has a happy ending in the case of HG. This population is often stigmatized due to practitioner bias and skepticism regarding severity of symptoms. I encourage the medical community to realize the gravity of this condition, which is associated with increase rates of termination of pregnancy and suicidal ideation.

I have written a poem dedicated to my wife and all the women who have experienced hyperemesis gravidarum. I hope and pray that it fosters reflection.

White porcelain welcomes two feeble disturbed patellae into their familiar position.

Exhausted cranium searches her way toward the bowl that yeans for a day without chartreuse liquid.

Listless larynx sighs to the angelic parasite: 3 months

A personal reflection on the psychological impact of hyperemesis gravidarum. 

Psychosomatics