This letter from Susan Dime-Meenan, Executive Director of the National Depressive and Manic Depression Association (NDMDA) was procured by Support Coalition under the Freedom of Information Act.

May 5, 1995

Bernard S. Arons, M.D.
Center for Mental Health Services
Rockville, MD 20857

Dear Dr. Arons,

I am writing to share the National Depressive and Manic-Depressive Association's (National DMDA) concerns regarding the Center for Mental Health Services' (CMHS) recent note to interested parties regarding electroconvulsive therapy (ECT), involuntary treatment, and related issues.

We appreciate CMHS's interest in furthering communication and debate on this issue. Involuntary treatment - whether through the use of ECT, prescription drugs, or any other means - is indeed a complex issue. Access to ECT, as well as for all medical care, must be subject to complete, continuing informed consent. At the same time, National DMDA strongly supports an individual's right to receive any safe and effective treatment for psychiatric illnesses, including electroconvulsive therapy.

Unfortunately, the stigma surrounding ECT prevents many Americans from receiving this valuable treatment. We believe that CMHS's recent statement missed an opportunity to provide much-needed federal leadership in combating this problem, and instead helped contribute to it by giving the impression that CMHS and the general medical community harbor doubts about the use of ECT under patient consent. Although the authority to determine which treatments are safe and effective and which are not rests solely with the Food and Drug Administration (FDA), CMHS is the lead federal agency dedicated to working on mental health services issues. As such, we find it alarming that CMHS did not explicitly state that it shares the broad support within the scientific, provider and consumer communities for the appropriate, consensual use of ECT as a safe and effective treatment for certain cases of severe depression and other mental disorders.

While we are primarily concerned with what the statement failed to convey, we are also concerned with the tight linkage in the statement between ECT and involuntary treatment. The statement implies that ECT is the treatment of concern in involuntary situations, giving little attention to the large preponderance of other forms of involuntary treatment. The statement's strong association of ECT with involuntary treatment also gives the impression that ECT is typically used in involuntary situations. In fact, in the large majority of cases ECT is used under patient consent.

Finally, we are concerned that in issuing this statement on a highly sensitive issue CMHS appears to have been largely responding to concerns voiced by opponents of psychiatry. National DMDA would have appreciated the opportunity to provide its perspective - prior to the statement's release - as the only patient-run organization advocating on behalf of those with depressive disorders.

We urge CMHS to retract the statement, and to replace it with one making clear that ECT is a safe and effective treatment which must be made available for the treatment of certain mental disorders, including severe depression. Pleas do not lose sight of your agency's mission to provide leadership in fighting for the widespread availability of effective mental health treatments. Those who would ban ECT and attack psychiatry are to be aggressively responded to - not accommodated.

Thank you for your time and attention to this matter.

Sincerely,

Susan Dime-Meenan
Executive Director
NDMDA

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"Consumers/survivors have fought for improved and more accessible mental health services ... for equal protection under the law ... and for the elimination of stigmatizing attitudes.

We still have a long way to go. But we have made tremendous progress in educating people inside and outside of the Capitol Beltway and it State Houses throughout the nation.

Our experience with state consumer affairs programs has provided us models for others to follow. We have learned a great deal from these initiatives:

First, we have learned that consumers and bureaucrats can be effective partners in ensuring the quality, accessibility and appropriateness of mental health programs and services. Second, we have learned that state offices of consumer affairs maximize their potential when state health officials initiate policies and build programs that are responsive to the needs of consumers. The good state health director listens to consumers, considers their ideas, and paves the way to implement initiatives that will improve the lives of people with mental illnesses. And third, state OCAs work best when state health directors solicit, open and maintain channels of communication with the consumer community. Ongoing feedback is perhaps the most critical factor in the success of state OCAs. We are applying these principles at the Center for Mental Health Services.

For example, we are laying the foundation to establish a consumer/survivor task force to advise the Center on issues related to the movement. It also will explore new opportunities to improve CMHS policies and programs."

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A Survivor Battles to Stop Controversial Therapy

By JOY HICKSON Lethbridge Herald

Seven years ago, Wendy Funk-Robitaille was a different person.

At 32, she was living in Medicine Hat, happily married with two children, had a job as a social worker, was working on her master's degree and planning to go to law school.

But after being diagnosed and treated, including electric shock, for depression, Funk-Robitaille was left a shell of her former self, unable to read, drive or even remember how to find her bathroom.

She had lost almost a lifetime of memories, including knowing her husband and sons.

In the years since, she has been able to recover to a degree, thanks largely to the support of her husband, Dan Robitaille.

But she has discovered she is not the only one who feels scarred by psychiatric treatment and he's started a support group called Crusaders Against Psychiatry.

"I would like to see ECT (electroconvulsive therapy or shock treatment) banned and some kind of tighter control on psychiatrists," she says. "I want other people to realize this could happen to you."

Members of her group, CAP, believe psychiatry "is a brainwashing technique which damages the brain and destroys memory," she says.

"I think mental health care is a scam. Professionals are in it to make money."

Robitaille's treatment began after a visit to a doctor whom she'd never seen before to treat a sore throat.

She had been under considerable stress because she had recently been raped at work. That, a heavy workload and the pain of a sore throat caused her to burst into tears in the doctor's office. The doctor determined she might be suffering from depression and prescribed Prozac.

Side effects of the antidepressant drug, affecting her sleep and eating patterns, made her feel worse and Funk-Robitaille's treatment snowballed to include more medication and eventually ECT.

After 43 shock treatments in a 14 month period and dozens of pills, she knew she needed a change.

"I decided this was not the way to live," Funk-Robitaille says. "I flushed the pills down the toilet."

Then she went to a psychiatrist in Calgary who determined she no longer needed treatment, but said her amnesia was probably permanent.

Now living in Lethbridge, Funk-Robitaille has re-learned most life skills and had another baby three years ago.

But life is still a struggle, she says

Many memories have been lost and some of her abilities, such as with math, are impaired.

"I can't remember my older sons' (ages 15 and 17) births or our wedding," she says. "I have a record in my picture albums and diaries, but it' not the same."

She thought her experience was an isolated incident until she saw a television talk show about the same thing happening to other people.

"I couldn't believe it," she says thought I was the only one. Then I knew there had to be other people this area who'd had bad experience and want to survive."

She has gone on local talk show herself, and is planning to publish, book on her experience.

"(Psychiatric treatment) took away my career, my past is gone and my future is shaky," she says.

"I just want to raise my family a give them the best life possible. And I want to tell others to be careful of people who they think can help the cope with life. Find alternatives to taking chemicals."

And she wants people who have had damaging treatment to know "there is hope for survival after psychiatry." For more information about CAP people may call Funk Robitaille at 381-6582

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Here are the stages of burnout. Especially for people with physical, emotional and mental exhaustion, unrealistically high aspirations and who are rigid perfectionists.

If in the beginning your job seems perfect, the solution to all your problems, you have high hopes and expectations, and would rather work than do anything else, be wary. You're a candidate for the most insidious and tragic kind of job stress--burnout, a state of physical, emotional, and mental exhaustion caused by unrealistically high aspirations and illusory and impossible goals.

Potential for burnout increases dramatically depending on who you are, where you work, and what your job is. If you're a hard worker who gives 110 percent, an idealistic, self-motivated achiever who thinks anything is possible if you just work hard enough, you're a possible candidate. The same is true if you're a rigid perfectionist with unrealistically high standards and expectations. In a job with little recognition and few rewards for work well done, particularly with frequent people contact or deadlines, you advance from a possible to a probable candidate.

The road to burnout is paved with good intentions. There's certainly nothing wrong with being an idealistic, hardworking perfectionist or self-motivating achiever, and there's nothing wrong with having high aspirations and expectations. Indeed, these are admirable traits in our culture. Unreality is the villain. Unrealistic job aspirations and expectations are doomed to frustration and failure. The burnout candidate's personality keeps him striving with single-minded intensity until he crashes.

Burnout proceeds by stages that blend and merge into one another so smoothly and imperceptibly that the victim seldom realizes what happened even after it's over.

These stages include:

1. The Honeymoon

During the honeymoon phase, your job is wonderful. You have boundless energy and enthusiasm and all things seem possible. You love the job and the job loves you. You believe it will satisfy all your needs and desires and solve all your problems. You're delighted with your job, your co-workers and the organization.

2. The Awakening

The honeymoon wanes and the awakening stage starts with the realization that your initial expectations were unrealistic. The job isn't working out the way you thought it would. It doesn't satisfy all your needs; your co-workers and the organization are less than perfect; and rewards and recognition are scarce.

As disillusionment and disappointment grow, you become confused. Something is wrong, but you can't quite put your finger on it. Typically, you work even harder to make your dreams come true. But working harder doesn't change anything and you become increasingly tired, bored, and frustrated. You question your competence and ability and start losing your self-confidence.

3. Brownout

As brownout begins, your early enthusiasm and energy give way to chronic fatigue and irritability. Your eating and sleeping patterns change and you indulge in escapist behaviors such as sex, drinking, drugs, partying, or shopping binges. You become indecisive, and your productivity drops. Your work deteriorates. Co-workers and superiors may comment on it.

Unless interrupted, brownout slides into its later stages. You become increasingly frustrated and angry and project the blame for your difficulties onto others. You are cynical, detached, and openly critical of the organization, superiors, and co-workers. You are beset with depression, anxiety, and physical illness. Drugs or alcohol are often a problem.

4. Full Scale Burnout

Unless you wake up and interrupt the process or someone intervenes, brownout drifts remorselessly into full-scale burnout. Despair is the dominant feature of this final stage. This may take several months, but in most cases it involves three to four years. You experience an overwhelming sense of failure and a devastating loss of self-esteem and self-confidence. You become depressed and feel lonely and empty.

Life seems pointless and there is a paralyzing, "what's the use" pessimism about the future. You talk about, "just quitting and getting away." Your are exhausted physically and mentally. Physical and mental breakdowns are likely. Suicide, stroke, or heart attack are not unusual as you complete the final stage of what all started with such high hopes, energy, optimism, and enthusiasm.

5. The Phoenix Phenomenon

You can arise Phoenix-like from the ashes of burnout, but it takes time. First of all, you need to rest and relax. Don't take work home. If you're like most, the work won't get done and you'll only feel guilty for being "lazy."

In coming back from burnout, be realistic in your job expectations, aspirations, and goals. Whomever you're talking to about your feelings can help you, but be careful. Your readjusted aspirations and goals must be yours and not somebody else's. Trying to be and do what someone else wants you to be or do is a surefire recipe for continued frustration and burnout.

A final tip--create balance in your life. Invest more of yourself in family and other personal relationships, social activities, and hobbies. Spread yourself out so that your job doesn't have such an overpowering influence on your self-esteem and self-confidence.

Adapted from The Stress Solution by Lyle H. Miller, Ph.D., and Alma Dell Smith, Ph.D.

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Stress in the workplace, job stress, traumatic events on the job and a work setting that creates physical stress can all cause anxiety at work.

In today's economic upheavals, downsizing, layoff, merger, and bankruptcies have cost hundreds of thousands of workers their jobs. Millions more have been shifted to unfamiliar tasks within their companies and wonder how much longer they will be employed. Adding to the pressures that workers face are new bosses, computer surveillance of production, fewer health and retirement benefits, and the feeling they have to work longer and harder just to maintain their current economic status. Workers at every level are experiencing increased tension and uncertainty, and are updating their resumes.

The loss of a job can be devastating, putting unemployed workers at risk for physical illness, marital strain, anxiety, depression, and even suicide. Loss of a job affects every part of life, from what time you get up in the morning, to whom you see and what you can afford to do. Until the transition is made to a new position, stress is chronic.

A Sense of Powerlessness

A feeling of powerlessness is a universal cause of job stress. When you feel powerless, you're prey to depression's traveling companions, helplessness and hopelessness. You don't alter or avoid the situation because you feel nothing can be done.

Secretaries, waitresses, middle managers, police officers, editors and medical interns are among those with the most highly stressed occupations marked by the need to respond to others' demands and timetables, with little control over events. Common to this job situation are complaints of too much responsibility and too little authority, unfair labor practices, and inadequate job descriptions. Employees can counteract these pressures through workers' unions or other organizations, grievance or personnel offices or, more commonly, by direct negotiations with their immediate supervisors.

Your job description

Every employee should have a specific, written job description. Simply negotiating one does more to dispel a sense of powerlessness than anything else we know. It is a contract that you help write. You can object to what and insist on what you do want. If there is a compromise, it's because you agreed to it. With a clear job description, your expectations are spelled out, as are your boss's.

A good job description is time limited. Set a specific date for a review and revision based on your mutual experience with this initial job description. If you and your boss can't agree on what your job description should be, look for another job, either within the same company or outside. Even in these tough economic times, it is important that your job be a source of satisfaction and respect.

When You're a Square Peg and Your Job is a Round Hole

Remember the old saying, "Find a job you love and you'll never work another day in your life." Most people spend about 25 percent of their adult lives working. If you enjoy what you do, you're lucky. But if you're the proverbial square peg and your job is a round hole, job stress hurts your productivity and takes a serious toll on your mind and body.

There are many reasons for staying in a job that doesn't fit you or that you don't particularly like. One reason can be the "golden handcuff"--having salary, pension, benefits, and "perks" that keep one tied to a job regardless of stress consequences.

Many people are in jobs they don't like or aren't good at. The quick answer is to get a job they like or one that better matches their skills, abilities, and interest--easier said than done. Some clients have no idea what kind of job they would like or what kind of job would be better. Worse, they don't have a clue on how to go about finding out this information.

Traumatic Events on the Job

Some jobs are inherently dangerous and others can suddenly become so. Criminal justice personnel, firefighters, ambulance drivers, military personnel, and disaster teams witness many terrible scenes and are exposed to personal danger routinely. They usually handle such incidents capably. But occasionally a particularly bad episode will stay with them, appearing in memory flashbacks and nightmares. Sleep disturbance, guilt, fearfulness, and physical complaints may follow. Even ordinary jobs can become traumatic: a coworker, boss, or client physically threatens an employee; a bus crashes on a field trip; an employee is robbed or taken hostage; a shooting occurs. Such events can create post-traumatic stress disorder (PTSD) and result in workers' compensation claims if left untreated by a trauma specialist.

Work Setting

Sometimes your work setting creates physical stress because of noise, lack of privacy, poor lighting, poor ventilation, poor temperature control, or inadequate sanitary facilities. Settings where there is organizational confusion or an overly authoritarian, lassiez-faire, or crisis-centered managerial style are all psychologically stressful.

Act through labor or employee organizations to alter stressful working conditions. If that doesn't work, try the courts, which have become increasingly receptive to complaints of stressful working conditions. Recent rulings created pressure for employers to provide working environments that are as stress free as possible.

The Occupational Safety and Health Administration (OSHA) is the federal agency charged with monitoring the work environment in the interest of work safety and health. If you think your work environment is dangerous to your health and safety from a physical standpoint, give them a call.

If nothing helps and the working environment remains stressful, exercise your avoidance options and get a new job. Job hunting can be stressful, particularly in times of high unemployment, but being ground down day after day by work is far worse.

Adapted from The Stress Solution by Lyle H. Miller, Ph.D., and Alma Dell Smith, Ph.D.

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Psychologists from around the world look at whether working mothers' multiple roles place inordinate stress on them. Are working moms holding up?

Does having a job as well as a home and a family enhance a woman's health or threaten it? Research on the question is sparse and contradictory.

Research in the area has pointed to two competing hypotheses, according to participant Nancy L. Marshall, EdD, of Wellesley College's Center for Research on Women.

One, the "scarcity hypothesis," presumes that people have a limited amount of time and energy and that women with competing demands suffer from overload and inter-role conflict.

The other, the "enhancement hypothesis," theorizes that the greater self-esteem and social support people gain from multiple roles outweigh the costs. Marshall's own research supports both notions.

Citing results from two studies she recently conducted, she explained that having children gives working women a mental and emotional boost that childless women lack. But having children also increases work and family strain, indirectly increasing depressive symptoms, she found.

The reason multiple roles can be both positive and negative has to do with traditional gender roles, agreed the experts who spoke at the session. Despite women's movement into the paid labor force, they still have primary responsibility for the "second shift" - household work and child care.

Workload scale

To study the area further, Ulf Lundberg, PhD, professor of biological psychology at the University of Stockholm, developed a "total workload scale." Using the scale, he has found that women typically spend much more time working at paid and unpaid tasks than men.

Lundberg also found that age and occupational level don't make much difference in terms of women's total workload. What does matter is whether they have children. In families without children, men and women both work about 60 hours a week.

But, said Lundberg, "as soon as there is a child in the family, total workload increases rapidly for women." In a family with three or more children, women typically spend 90 hours a week in paid and unpaid work, while men typically spend only 60.

Women can't look forward to relaxing during evenings or weekends, either. That's because women have a harder time than men unwinding physiologically once they're home.

"Women's stress is determined by the interaction of conditions at home and at work, whereas men respond more selectively to situations at work," explained Lundberg, adding that men seem to be able to relax more easily once they get home.

His research found that mothers who put in overtime at their paid jobs had more stress - as measured by epinephrine levels - over the weekend than fathers, even though the fathers had worked more overtime at their jobs.

These findings come as no surprise to Gary W. Evans, PhD, of Cornell University's Department of Design and Environmental Analysis. He believes that stresses on women are cumulative rather than additive_that home and work stressors combine to put women at risk. While some models conceptualize stress as additive, research he's done on stress suggests that woman can't put out one fire and move on to the next without suffering from stressful overload.

Evans also emphasized that simply coping with stress takes a toll on women's well-being.

"There's a tendency to put coping in a positive light," he noted. "There are costs of coping, however. When we cope with a stressor, especially one that is incessant or difficult to control, our ability to cope with subsequent environmental demands can be impaired."

The social support solution

The debate about women's multiple roles could be rendered obsolete by changes in societal expectations, many experts in the field believe.

"Individual decisions about work and family take place in a social and cultural context," said Gunn Johansson, PhD, professor of work psychology at the University of Stockholm. "Society sends encouraging or discouraging signals about an individual's choices and about the feasibility of combining work and family."

According to Johansson, these signals come not only in the form of equal employment opportunity laws, but also in the support society makes available to families. A researcher in her department, for instance, compared the plight of women managers in Sweden and the former West Germany. Although the two societies are quite similar, they differ in one important respect: Sweden offers high-quality child care to almost every family that requests it.

Preliminary results from the study are striking. In Sweden, most of the women managers had at least two children and sometimes more; in Germany, most were single women with no children.

"These women were reading the signals from their society," Johansson said. While the German women recognized that they had to forsake family for work, the Swedish women took it as their right to combine the two roles.

"In my optimistic moments," Johansson added, "I hope that this research might provide information that would prompt politicians to provide opportunities for both women and men. Women need to feel that they have a real choice when it comes to balancing work and family life."

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Psychologists explore how personality affects ability to perform well on the job.

Mom always said that personality and smarts go farther than good looks. And now even psychologists are on her side.

For years psychologists turned to cognitive ability as a predictor of job performance: Smarter people were considered more likely to succeed on the job. But intelligence alone is only part of the story, say researchers. Creativity, leadership, integrity, attendance and cooperation also play major roles in a person's job suitability and productivity. Personality, rather than intelligence, predicts these qualities, said psychologist Joyce Hogan, PhD, of the University of Tulsa.

Armed with this belief, psychologists are trying to tease out personality's impact on overall job performance. Although they haven't unraveled the details, most agree that personality is as important as intelligence, and maybe more so, for some aspects of performance.

Most psychologists base personality research on the "Big Five" classification of personality traits: extraversion, agreeableness, conscientiousness, emotional stability and openness to experience. The classification isn't perfect, but it provides a good foundation for studying broad effects of personality, researchers say. Some researchers contend that, like intelligence researchers who claim to have a general measure of intelligence, they have found the universal personality trait that predicts job success. Others argue that the relationship between personality and job success is much more complicated and shouldn't be condensed into a have and have- ­not scenario.

The 'g' of personality

One research camp argues that conscientiousness -- being responsible, dependable, organized and persistent -- is generic to success. "It seems to predict job performance for any job you can think of," said Michael Mount, PhD, a psychologist at the University of Iowa. Mount and his colleagues analyzed more than 117 studies of personality and job performance. Conscientiousness consistently predicted performance for all jobs from managerial and sales positions to skilled and semiskilled work. Conscientiousness is the only personality trait fundamental to all jobs and job- ­related criteria, said Mount. Other traits are valid predictors for only some criteria or occupations. The researchers are testing their hypothesis on practical personnel problems. For example, to determine which truck drivers would stay on the job longest, researchers tested them on the Big Five. Drivers who were more conscientious performed better and remained on the job longer than less conscientious drivers.

Matching people to jobs

But using conscientiousness as a standard of job performance won't work for all jobs, said Hogan. "Conscientiousness has a bright side and a dark side," she said. Her research shows that for some jobs -- particularly creative ones -- conscientiousness may be a liability, rather than an asset. In a sample of musicians from the Tulsa, Okla., music community, Hogan found that the best musicians, as rated by their peers, had the lowest scores on conscientiousness. She wants researchers to think about matching people to jobs by crossing the Big Five personality dimensions with the occupations taxonomy developed by Johns Hopkins University psychologist John Holland, PhD, in the early 1970s. Holland separated occupations into six themes including realistic jobs -- mechanics, fire fighters, construction workers; conventional jobs -- bank tellers and statisticians; and artistic jobs -- musicians, artists and writers. While conscientiousness predicts performance in realistic and conventional jobs, it impedes success in investigative, artistic and social jobs that require innovation, creativity and spontaneity, said Hogan. "There are jobs where you have to have creativity and innovation," said Hogan. "If you select employees based on conscientiousness, you won't come close to getting creative or imaginative workers." Rather, such workers should measure high on openness to experiences and low on conscientiousness, she said. Mount agrees that artistic people require creativity and innovation, but he's not convinced they can be successful if devoid of conscientiousness. His studies have even found a moderate correlation between conscientiousness and creativity, he said. The key may lie in timing, according to data collected over 50 years by graduates of Mills College. For them, ambition, which is related to extraversion, predicted whether a woman entered the work force and how well she did. Highly conscientious women tended to not enter the work force and didn't do as well when they did, said Brent Roberts, PhD, of the University of Tulsa. But these women had to swim against the current to enter the workforce when they did, said Roberts. Furthermore, successful, ambitious women, low on conscientiousness, became more conscientious the longer they worked. This implies that ambition gets the job and working promotes conscientiousness, which helps keep the job, said Roberts.

Add social skills

Interpersonal skills have recently caught Hogan's attention as predictors of job performance.

"They are the icing on the personality cake," she said. "Interpersonal skills can energize or inhibit natural personality tendencies." For example, a naturally introverted person with good interpersonal skills can muster enough extraversion to make a public speech, she said. Likewise, a naturally hostile and aggressive person can appear sweet and charming, she added.

As the workplace moves toward teamwork and service- ­oriented jobs, evaluating interpersonal skills becomes increasingly important, said Hogan. But it's difficult to study these skills because no classification system exists. She is working on a model classification system that would include sensitivity to others, trust and confidence, responsibility, accountability, leadership and consistency.

The traditional one- ­dimensional definition of job performance as equal to task performance overshadows the importance of personality and interpersonal skills and accentuates the importance of intelligence, according to psychologist Stephan Motowidlo, PhD, of the University of Florida at Gainesville. He prefers to separate job performance into two parts: task performance and contextual performance. Task performance is the traditional notion of ability: how well workers perform and complete a specific task -- a fire extinguished, a student taught, a story written, for example.

Contextual performance measures aspects of performance unrelated to specific tasks -- volunteering, putting in extra effort, cooperating, following rules and procedures, and endorsing the goals of the organization -- that are equally important to job performance. His research shows that task performance and contextual performance contribute independently to overall job performance. Furthermore, job experience predicted task performance better than it predicted contextual performance. In contrast, personality predicted contextual performance better than it predicted task performance.

Contextual performance can be further separated into two facets: job dedication -- working hard, volunteering, committing to the organization -- and interpersonal facilitation -- cooperating, helping others. Personality affects the two facets differently. Conscientiousness predicts job dedication, while extraversion and agreeableness predict interpersonal facilitation. Interestingly, job dedication appears to affect both task performance and interpersonal facilitation. But the model also indicates the importance of extraversion, agreeableness and interpersonal skills.

Today's emphasis on teams, service jobs and treating colleagues as customers promotes the importance of looking at the softer side of job performance, said Motowidlo. And although people disagree on exactly how personality fits in, they're all heading in the same direction.

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For some of us, a job is a labor of love. For others, it's the sole means by which we support our families. And for many, a job can be an overwhelming source of stress.

 We face a variety of situations at work, and there is a commonality to those which cause us the most stress.

Whether it's being laid off, dealing with a difficult boss, having anxiety about job security or coping with an excessive workload, things happen every day at work that can result in undue stress on our emotions.

Ever since

the big lay-off, weird things started happening to me. I couldn't sleep or eat. I'd scream at my kids for the littlest things. My job had become a living nightmare. I was doing the work of three people. The pressure never stopped. And instead of saying thanks, my boss acted like I was lucky to still be here. Every day I'd wonder if I was next to get the axe. A friend at work gave me the name of a psychologist. At first, I said, "No way." But finally, I realized I couldn't fix this on my own. So I went. And it helped. I found constructive ways to deal with this situation, work better with my boss and manage the stress. My psychologist smiles when I tell her she saved my life. I know for sure she saved my job.

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Review of studies to evaluate whether women are at greater risk for PTSD than men.

Differences between the sexes regarding the prevalence, psychopathology and natural history of psychiatric disorders have become the focus of an increasingly large number of epidemiological, biological and psychological studies. A fundamental understanding of sex differences may lead to a better understanding of the underlying mechanisms of diseases, as well as their expression and risks.

Community studies have consistently demonstrated a higher prevalence of posttraumatic stress disorder (PTSD) in females than in males. Recent epidemiologic studies conducted by Davis and Breslau and summarized in this article have begun to elucidate the causes of this higher prevalence of PTSD in women.

Davis and Breslau's studies addressing this issue include Health and Adjustment in Young Adults (HAYA) (Breslau et al., 1991; 1997b; in press) and the Detroit Area Survey of Trauma (DAST) (Breslau et al., 1996).

In the HAYA study, in-home interviews were conducted in 1989 with a cohort of 1,007 randomly selected young adult members, between the ages of 21 and 30, of a 400,000-member HMO in Detroit and surrounding suburban areas. Subjects were reevaluated at three and five years post-baseline interview. The DAST is a random digit dialing telephone survey of 2,181 subjects between the ages of 18 and 45, conducted in the Detroit urban and suburban areas in 1986. Several national epidemiologic studies that report sex differences in PTSD include the NIMH-Epidemiologic Catchment Area survey (Davidson et al., 1991; Helzer et al., 1987) and the National Comorbidity Study (Bromet et al.; Kessler et al., 1995).

Epidemiologic studies, particularly those focusing on the evaluation of risk factors for illness, have a long and distinguished history in medicine. However, it is important to understand that the proposition that there are factors predisposing individuals to the risk for PTSD was controversial in the early phase of characterizing this diagnosis. Many clinicians believed that a highly traumatic stressor was sufficient for the development of PTSD and that the stressor alone "caused" the disorder. But even early studies demonstrated that not all, and often a small number of, individuals exposed to even highly traumatic events develop PTSD.

Why do some individuals develop PTSD while others do not? Clearly, factors other than exposure to adverse events must play a role in the development of the disorder. In the late 1980s, a number of investigators began to examine risk factors that might lead not only to the development of PTSD, recognizing that the identification of risk factors should lead to a better understanding of the pathogenesis of the disorder, but also to a better understanding of the commonly comorbid anxiety and depression in PTSD and, most importantly, to the development of improved treatment and prevention strategies.

Since the diagnosis of PTSD is dependent upon the presence of an adverse (traumatic) event, it is necessary to study both the risk for the occurrence of adverse events and the risk for developing the characteristic symptom profile of PTSD among exposed individuals. One fundamental question addressed by the analysis of both types of risk is whether differential rates of PTSD could be due to differential exposure to events and not necessarily to differences in the development of PTSD.

Early epidemiologic studies identified risk factors for exposure to traumatic events and subsequent risk for the development of PTSD in such exposed populations (Breslau et al., 1991). For example, alcohol and drug dependence was found to be a risk factor for exposure to adverse events (such as automobile accidents), but was not a risk factor for the development of PTSD in exposed populations. However, a prior history of depression was not a risk factor for exposure to adverse events but was a risk factor for PTSD in an exposed population.

In an initial report (Breslau et al., 1991), the evaluation of risk of exposure and risk of PTSD in exposed individuals demonstrated important sex differences. Females did have higher prevalence of PTSD than males. Females were somewhat less likely to be exposed to adverse traumatic events but were more likely to develop PTSD if exposed. Thus, an overall increased prevalence of PTSD in females must be accounted for by a significantly greater vulnerability to develop PTSD after exposure. Why is this?

Before we attempt to answer this question, it is important to examine the overall pattern of a lower burden of trauma in females than in males. The fact that women are exposed to fewer traumatic events obscures an important variation across "types of traumatic events." In the DAST (Breslau et al., in press), adverse events are classified into various categories: assaultive violence, other injury or shocking event, learning of traumas of others, and sudden unexpected death of relative or friend. The category with the highest rates of PTSD is assaultive violence.

Do females experience proportionately more assaultive events than males? The answer is no. Actually, males experience assaultive violence more frequently then females. Assaultive violence as a category is composed of rape, sexual assault other than rape, military combat, being held captive, being tortured or kidnapped, being shot or stabbed, being mugged, held-up, or threatened with weapons, and being badly beaten up. While females experience fewer assaultive events than males, they do experience significantly higher rates of one type of assaultive violence, namely rape and sexual assault.

Does a differential rate of rape and sexual assault between males and females account for the rates of PTSD? No. Females actually have higher rates of PTSD across all types of events in the assaultive violence category, both for events to which they are more exposed (rape) and for events to which they have less exposure (mugged, held-up, threatened with a weapon).

To provide a more quantitative picture from one study (Breslau et al., in press), the conditional risk of PTSD associated with exposure to any trauma was 13% in females and 6.2% in males. The sex difference in conditional risk of PTSD was due primarily to females' greater risk of PTSD following exposure to assaultive violence (36% versus 6%). Sex differences in three other categories of traumatic events (injury or shocking experience, sudden unexpected death, learning about traumas of a close friend or relative) were not significant.

Within the assaultive violence category, women had a higher risk of PTSD for virtually every type of event such as rape (49% versus 0%); sexual assault other than rape (24% versus 16%); mugging (17% versus 2%); held captive, tortured or kidnapped (78% versus <1%); or being badly beaten up (56% versus 6%).

To highlight these differences in PTSD risk, we can examine nonassaultive categories of events in both sexes. The single most frequent cause of PTSD in both sexes is sudden unexpected death of a loved one, but the sex difference was not large (this stressor accounted for 27% of female cases and 38% of male cases of PTSD in the survey). On the other hand, 54% of female cases and only 15% of male cases were attributable to assaultive violence.

Are there other differences between males and females with respect to PTSD? There are differences in the expression of the disorder. Women experienced certain symptoms more frequently then males. For example, females with PTSD more frequently experienced 1) more intense psychological reactivity to stimuli that symbolize the trauma; 2) restricted affect; and 3) exaggerated startle response. This is also reflected by the fact that females experienced a larger mean number of PTSD symptoms. This higher burden of symptoms was almost entirely due to the sex difference in PTSD following assaultive violence. That is, women with PTSD from assaultive violence had a larger burden of symptoms than did men with PTSD resulting from assaultive violence.

Not only do females experience a greater symptom burden than males but they have a longer course of illness; the median time to remission was 35 months for females, which contrasted to nine months for males. When only traumas experienced directly are examined, the median duration increases to 60 months in females and 24 months in males.

In summary, estimates of the lifetime prevalence of PTSD are approximately twice as high for females as for males. At present, we recognize that the burden of PTSD in females is associated with the unique role of assaultive violence. While males experience somewhat more assaultive violence, females are at far greater risk for PTSD when exposed to such traumatic events. Sex differences with respect to other categories of traumatic events are small. Although females' higher vulnerability to PTSD effects of assaultive violence is, in part, attributable to the higher prevalence of rape, the sex difference persists when this particular event is taken into account. The duration of PTSD symptoms is nearly four times longer in females than males. These differences in duration are largely due to the higher proportion of female PTSD cases attributable to assaultive violence.

Are women at greater risk for PTSD than men? Yes. How can we understand this finding? First of all, it is important to understand that other risk factors known to predispose individuals to PTSD do not demonstrate a sex difference. For example, prior depression predisposes individuals to the later development of PTSD but there is no interaction effect with sex. While we have confirmed and elaborated on a sex difference in the risk for PTSD, new questions have emerged: Why are females more likely to develop PTSD from assaultive violence, and why do females who develop PTSD have a greater burden of symptoms and a longer duration of illness than males who develop PTSD from assaultive violence? Further research is necessary and we can only speculate about the causes. Women are more frequently unwilling victims of violence while men may be active participants (barroom fights, and so forth).

Finally, there is greater physical inequality and injury risk for women than men. Women may experience more helplessness and, thus, have greater difficulty extinguishing the arousal (for example, enhanced startle reflex) and depressive symptoms (restricted affect).

About the authors:Dr. Davis is vice president of academic affairs at the Henry Ford Health System in Detroit, Mich., and a professor at Case Western Reserve University School of Medicine, department of psychiatry, Cleveland.

Dr. Breslau is director of epidemiology and psychopathology at the department of psychiatry at Henry Ford Health System in Detroit, Mich., and a professor at Case Western Reserve University School of Medicine, department of psychiatry, Cleveland.

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References

Breslau N, Davis GC, Andreski P, Peterson E (1991), Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 48(3):216-222.

Breslau N, Davis GC, Andreski P, Peterson EL (1997a), Sex differences in posttraumatic stress disorder. Arch Gen Psychiatry 54(11):1044-1048.

Breslau N, Davis GC, Peterson EL, Schultz L (1997b), Psychiatric sequelae of posttraumatic stress disorder in women. Arch Gen Psychiatry 54(1):81-87.

Breslau N, Kessler RC, Chilcoat HD et al. (in press), Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. Arch Gen Psychiatry.

Bromet E, Sonnega A, Kessler RC (1998), Risk factors for DSM-III-R posttraumatic stress disorder: findings from the National Comorbidity Survey. Am J Epidemiol 147(4):353-361.

Davidson JR, Hughes D, Blazer DG, George LK (1991), Post-traumatic stress disorder in the community: an epidemiological study. Psychol Med 21(3):713-721.

Heizer JE, Robins LN, Cottier L (1987), Post-traumatic stress disorder in the general population: findings of the Epidemiologic Catchment Area Survey. N Engl J Med 317:1630-1634.

Kessler RC, Sonnega A, Bromet E, Hughes M et al. (1995), Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 52(12):1048-1060.

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(sometimes anxiety and depression go hand-in-hand, as attested to by this young woman who writes about "feeling blue")

annabel loo was feeling blue,
she asked herself, what should I do?
something feels a little bad,
how do I fix this feeling sad?

she told herself I need to see
exactly what is bothering me
so she thought and thought through all her fears
and the big world blurred from all her tears.

with tissues piled on either side
annabel sighed, i'm glad I cried.
now i've fixed whatever was wrong.
now the sadness should be gone
so she sat down and looked inside... HOLY COW!
it was bigger now.

but annabel was one tough pup
she told herself, I won't give up.
i'll tell my friends i'm feeling blue,
i'm sure that they'll know what to do.

simone said, things, they aren't so sad.
sam said, your life ain't half bad.
the other day at burger king,
my brother puked an onion ring.
annabel said, that's rough, sam-man.
but inside she thought, this was a bad plan.

then, annabel was not just sad,
now add to sad, she felt quite bad.
the past two plans didn't work at all,
and still remained the sadness flaw.

I hate this horrible sticky sadness,
the feeling badness.
this must be madness.

if everyone said I should be happy,
maybe the problem is all just me.

and then the sadness got much worse,
for annable had cast a curse.
sadness and blueness are tough to bout,
but they're nothing compared to the worst,
self-doubt.

now, on top of feeling blue,
annabel is sad,
feels bad, thinks she's mad,
WHAT TO DO?!?

some of us can sit through sadness,
but others, this can drive to madness.

what's the difference between these two?
is it just that some people don't feel blue?
no, you silly, it's what you do
when a bit of blueness falls on you.

there is a myth that goes like this
every moment should be filled with happiness.
the truth is there isn't always a cure
sometimes we simply have to endure.

so if you're having a miserable day,
be a grump, feel that way.
just feel the way you need to feel,
the truth is it's just no big deal.

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