Today is the town wide clean up, with residents walking the edges of the streets, clearing the past year's accumulation of litter. The number of nip and beer bottles, and cigarette butts appearing like weeds in grass, far outnumber the coffee cups, soda and water containers, or even candy wrappers. We dutifully fill our plastic bags with the remnants of stories the empty containers tell, complicit in hiding them as they head to the dump. Yet it isn't uncommon to read of fatal car accidents attributed to alcohol intoxication, or to know intimately people whose lives are fractured by the effects of alcohol.
Historically, we have treated issues of substance abuse and depression, along with a myriad of other conditions such as COPD, heart disease, obesity, hepatitis and autoimmune diseases, as unrelated entities. But are they?
Dr. Vincent Felitti from Kaiser Permanente in San Diego, Calif., and Dr. Robert Anda from the Centers for Disease Control created a questionnaire, completed by 17,000 people, known as the Adverse Childhood Experiences (ACE) Study. The results from this pivotal research have begun to connect the dots. "The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of" is the title of a Jane Stevens' article, and Dr. Robert Block, the former president of the American Academy of Pediatrics is quoted by Sherry Peters, MSW in an article as opining "Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation."
The ACE study consisted of 10 questions identifying various types of adverse life events including abuse, household dysfunction, and neglect. According to Anda, "ACEs disrupt neurodevelopment and can have lasting effects on brain structure and function." Felitti and Anda in The Hidden Epidemic (2009) also correlate ACEs to autoimmune illness, implying an effect of such experiences on the immune system.
Felitti describes the effect of ACEs on the Kaiser Permanente sample: Greater than 50 percent of the "middle-class population of Health Plan members" experienced at least one ACE. Experiencing one ACE increased the chance of exposure to another by 80 percent. Cumulative ACEs strongly predicted health disorders in adulthood such as depression, COPD, IV drug use, suicide attempts, heart disease, obesity, diabetes, alcoholism, and others. Some of the percentage increases are startling: a 4,600 percent increase in incidence of IV drug use for males with an ACE score of 6. Someone with an ACE score of 4 or more was 460 percent more apt to suffer from depression than someone with an ACE score of 0.
The effects of ACEs cost billions of dollars in lost workplace productivity. ACEs drive huge expenditures on antidepressants. We are focused as a nation on decreasing health costs but it seems some of our current practices are counterproductive.
Some therapies with evidence of success in treating symptoms associated with trauma include Prolonged Exposure Therapy (PE), Cognitive Processing Therapy (CPT), and Eye Movement and Desensitization and Reprocessing (EMDR). Ninety-minute PE and EMDR sessions are known to produce benefit. Most insurance companies cover the cost of 45 minute appointments. This fact precludes people with limited means from receiving treatment known to be successful. Furthermore, therapists are pressured to write a computer note during a person's session, a practice called collaborative documentation. The therapies we've mentioned make this practice next to impossible, but clinic managers push nonetheless for this time-saving method. We have the clinical tools, but we don't have the means to use them effectively.
Another impinging factor includes 15-to 20-minute appointments with advance practice nurses, physician assistants or psychiatrists. These constraints don't allow for exploration of ACEs or for anything beyond strict medication management. The short appointments do not provide opportunity for people to be heard.
We can no longer afford the separation of physical health and psychological wellbeing. Systems need to come together in an effort to treat people as whole beings imprinted by their history of experiences. Not only is this the ethical imperative, but it seems to be the most effective means of improving the health of our nation while decreasing health care costs.
Carolyn Sacco, RN has worked as a nurse in psychiatry since 1985, in inpatient hospital, outpatient clinic, and home settings. Jeffrey Geller, MD. MPH is professor of psychiatry at the University of Massachusetts Medical School. He also treats in- and outpatients.