A cigar is just a cigar

Regarding the November Monitor article on the roots of terrorism, to understand terrorism, it doesn't require years of analysis to concur with Freud that “sometimes, a cigar is just a cigar.”

Likewise, most times, desperately angry terrorists are just desperate and angry.

They're angry about real injustices they've suffered at the hands of those in power — who often abuse them further by using their outrage as proof they deserve to be treated unjustly.

Marvin Poston, PsyD
Charlotte, N.C.

An ethical dilemma

We appreciate Dr. Behnke describing some of the delicate ethical issues associated with counseling clients who are dying in his November article “A terminally ill patient's last request.” He nicely outlined several relevant points when a client asks her psychologist to sing at the client's funeral. Further, the client's dementia highlights the need to assess such clients regularly for decision-making capacity.

Based on the information presented, accepting the request does not seem unethical under the 2002 APA Ethics Code because there does not appear to be exploitation of the client, conflict of interest for the psychologist, or impaired judgment by either party. Therefore, the psychologist can ethically agree (or not) to the request. We highlight this point because many psychologists appear to believe that any form of multiple relationship is unacceptable and perhaps unethical.

Assumptions about the boundaries of the psychotherapeutic relationship may not hold when working with clients who are dying. Terminally ill clients may need different types of services or help from therapists — such as being seen at their home or in a hospital room.

In addition, in small communities, avoiding multiple relationships is especially difficult and attempting to do so could lead to detrimental effects both professionally and personally. Trust and acceptance may be difficult to establish or maintain if the psychologist avoids community involvement. Thus, practitioners are very likely to have multiple relationships with clients — for example, being active in the same religious institution.

Therefore, we recommend that psychologists working with dying individuals and providing services in small communities should be especially diligent about consultation, documentation and informed consent, and should be familiar with relevant literature.

James L. Werth Jr., PhD
Joshua Bradley

Radford University
Rebecca S. Allen, PhD
The University of Alabama
Dean Blevins, PhD
North Little Rock, Ark.

Antidepressants and children

The November “Upfront” piece “Antidepressants and children: Too little or too much?” offered several sweeping claims made that perpetuate the attribution bias regarding the use of antidepressants in youth and their effectiveness.

First, as a result of the FDA's antidepressant warnings for their use in youth, the article claims that “unintended consequences” could have contributed to an 18 percent increase in youth suicide rates from 2003 to 2004. In fact, the increase that was cited is only an 8 percent increase. Antidepressant prescription rates for this (under 18) group had significantly increased since 1995–96 to the 2003–04 timeframe referenced in the article. These rates were 1.9 per 100 in 1995–96 soaring to 8.0 per 100 in 2003–04. The implications of this are significant. Although your article cites a trending downward of suicide from 1990 to 2003, more recent data from 2000 to 2004 show a reversal in this trend. During this span, the suicide rate for adolescent females (age 5 to 24) was trending upward. For males, a slight reduction was shown.

The National Center for Health Statistics has released data for 2005 within their 2008 Health Statistics. In 2004, the suicide rate for males age 5 to 19 was 13.5 per 100,000. In 2005, this rate was 13.1. For females age 5 to 19, 2004 showed a rate of 4.0 per 100,000 of completed suicides. In 2005, this rate fell to 3.3 per 100,000. Combined, this is a 7.3 percent reduction.

Importantly, the National Center for Health Statistics has also revealed important data regarding adolescents “seriously considering” suicide. As noted, the FDA Warning was based, in part, on an increased likelihood of suicidal ideation after antidepressant exposure. Across virtually all adolescent age groups (divided by academic grades), adolescents “seriously considering” suicide have declined from 2003 to 2007.

Finally, the Treatment of Adolescent Depression Study is considered by many to be an authoritative study on the use of antidepressants, CBT and combined treatments. The Suicidal Ideation Questionnaire was used within the TADS study. CBT and Placebo actually outperformed fluoxetine in reducing this score from baseline to 12 weeks. Moreover, in a one year naturalistic follow-up following completion of the study (TADS TEAM, 2009), data revealed that youth achieved essentially the same outcomes, regardless of treatment received. (This is, by the way, quite reminiscent of the MTA data at three-year follow-up.)

The thrust of the “Upfront” article seemed to support the use of antidepressants in at least an adjunctive treatment strategy for adolescent depression, but it would appear — under close scrutiny — that the proven effectiveness of antidepressants in the treatment of adolescent depression remains to be seen.

Robert Foltz, PsyD
The Chicago School of Professional Psychology

Please send letters to Sara Martin, Monitor editor, at the APA address. Letters should be no more than 250 words and may be edited for clarity or space.