Informal communication among British veterans of the first Iraq war may have shaped the vets' characterization of Gulf War Syndrome.
After the bullets stopped flying, the rumors took off among British veterans of the 1991 Gulf War. Early accounts of physical and emotional reactions to wartime experiences spread from one person to another through networks of veterans. Within a few years, these former soldiers had decided among themselves that many of them suffered from the controversial illness known as Gulf War Syndrome, a new study concludes.
Simon Wessely of King’s College London and his colleagues analyzed extensive written accounts provided in 1996, five years after the Gulf War, by 1,100 British Gulf War vets participating in a larger survey of veterans’ health. Vets described their wartime experiences and related what had happened in the conflict to their later health and illness.
The research team doesn’t regard rumor as necessarily untrue or misleading. Rumor proved to be critical among the British Gulf War vets because it counteracted a lack of communication from military and government authorities regarding possible wartime health risks, Wessely says.
Scared and confused vets turned to their own social grapevine for answers, Wessely’s group reports in an upcoming Social Science & Medicine. Out of their shared stories and explanations grew a collective conviction that Gulf War Syndrome existed as a unitary illness with elusive causes.
“The nature of Gulf War Syndrome in the years after the conflict was keenly shaped by these early rumors, which entangled specific ideas about the illness with feelings of betrayal, distrust and ambiguity,” Wessely says.
Symptoms attributed to Gulf War Syndrome include joint and muscle pain, bouts of depression or violent behavior and cancers of various types. Some researchers regard the condition as a psychological disorder related to the stress of combat. Others, as well as many vets, contend that it’s a physical disorder caused by exposure to toxic substances shortly before or during the war.
By 2001, an estimated 15 percent to 20 percent of those who served in the Gulf War believed that they suffered from Gulf War Syndrome.
Current medical consensus holds that Gulf War veterans indeed display unusually high rates of various health problems, but that these conditions don’t constitute a discrete illness or syndrome, Wessely says.
Research on this issue remains contentious. In a commentary slated to be published with the new study, Thomas Shriver of Oklahoma State University in Stillwater and Sherry Cable of the University of Tennessee in Knoxville say that Wessely’s team appears to regard veterans’ symptoms as purely psychological and perhaps partly invented out of rumor. “The authors come perilously close to blaming the victims,” the two sociologists contend.
U.S. Gulf War vets used rumors early after their return to define collective grievances and develop a plan to press authorities for medical treatment and compensation, Shriver and Cable say.
But, Wessely responds, “Far from blaming vets, we are shifting the spotlight to the role of governments in allowing an information vacuum to develop regarding potential health risks, which allowed rumors to spread and gain currency after the war.”
Military authorities in the United States and England have learned a hard lesson from that experience, he says.
Consider that the anthrax vaccine was administered to U.S. and British soldiers entering the Gulf War, but that the vaccine was given under a code name. Rumors about the vaccine spread quickly, including one that soldiers were being injected with an experimental AIDS vaccine. Before the 2003 invasion of Iraq, U.S and British soldiers were told upfront that they were receiving the anthrax vaccine.
The new study confirms that rumors about health risks, especially from vaccinations and pills, spread rapidly among troops just before, during and after the war.
About 90 percent of the survey participants listed one or more personal problems, including anger, depression, forgetfulness, lumps, rashes, seizures, post-traumatic stress disorder, brain lesions, incontinence and self-enforced isolation.
More than one-third of vets worried about unknown pollutants that had somehow entered their bodies. Concern focused on exposure to depleted uranium used during the war by U.S. and British forces, tablets and vaccinations provided to protect against Iraqi biological and chemical warfare and smoke from oil fires set by Iraqi forces as they retreated from Kuwait.
About two-thirds of vets said that they did not, at the time of the survey, suffer from any full-blown illness but still felt susceptible to developing Gulf War Syndrome.
Most participants also cited a lack of confidence in their leaders, from commanders of military units to government officials. Frustration over military secrecy and over not knowing whom to trust was common.
After the war, rumors reaffirmed the social bond among returning vets and helped them to shape a bewildering array of physical and psychological symptoms into the common burden of Gulf War Syndrome, the scientists propose.
Research on the physiology of anxiety-related illness is still young, but evidence continues to grow of the mutual influence between emotions and physical functioning. An estimated 57 million adults suffer from anxiety disorders. They share an unwarranted fear or distress that interferes with daily life. Now, anxiety has been implicated in several chronic physical illnesses, including heart disease, chronic respiratory disorders and gastrointestinal conditions. When people with these disorders have untreated anxiety, the physical disease is more difficult to treat, symptoms often become worse and in some cases they die sooner.
Anxiety disorders are more prevalent in individuals with chronic physical illness compared to individuals with no such illness and about twice as prevalent in women as in men.
This study used data collected in the 2005 Canadian Community Health Survey (21,198 women and 20,478 men) to examine factors associated with comorbid anxiety disorders and to assess the relation of these disorders on short-term disability and suicidal ideation.
Comorbid anxiety disorders were more prevalent among women who were young, single, poor and Canadian-born and among women with chronic fatigue syndrome, fibromyalgia, bowel disorder or stomach or intestinal ulcers or bronchitis had the highest rates of anxiety disorders.
The presence of comorbid anxiety disorders was significantly associated with short-term disability, requiring help with instrumental daily activities and suicidal ideation.
Our findings underscore the importance of early detection and treatment of anxiety disorders in the physically ill, especially those who also suffer from mood disorders.
Physical illness as an outcome of chronic anxiety disorders
Bowen RC, Senthilselvan A, Barale A, Department of Psychiatry, University of Saskatchewan, Saskatoon : email@example.com - Can J Psychiatry. 2000 Jun;45(5):459-64 - PMID: 10900526
Background The literature indicates increased rates of some medical conditions in patients with anxiety disorders. We used the Saskatchewan Health databases to examine the development of nonpsychiatric medical diseases in patients with anxiety disorders. This study has a large population base, and the Saskatchewan health plan does not limit the provision of services to this population.
Method We observed the annual incidence of specified medical conditions in patients with anxiety disorders and in control subjects over a 10-year period. Subjects in both groups had not been treated for the specified medical conditions before the start of the observation period.
Results The anxiety cohort had a significantly higher relative risk of developing medical diseases compared with the control group. The highest relative risk, indicated by the hazard ratio, was for cerebrovascular disease (hazard ratio 2, 95% CI 1.09-3.65). Hazard ratios were significant for cerebrovascular disease and atherosclerosis as well as for ischemic heart, gastrointestinal, hypertensive and respiratory diseases.
Conclusions This study provides additional evidence for an association between anxiety disorder and the later development of medical morbidity.
Anxiety disorder A disorder where sufferers usually experience constant or repeated and exaggerated worry and tension for no appropriate reason. This can be accompanied by physical symptoms such as fatigue, trembling, muscle tension, headache and nausea. Anxiety disorders include generalised anxiety disorder, panic disorder, phobias, obsessive-compulsive disorder and post-traumatic stress disorder.
Comorbidity In medicine, comorbidity (literally "additional morbidity") is either : - the presence of one or more disorders (or diseases) in addition to a primary disease or disorder or - the effect of such additional disorders or diseases.
1. - Depression
Depression A mood disorder characterised by persistent feelings of sadness for several weeks or more. Depression is associated with feelings of worthlessness, helplessness and guilt and can lead to appetite and sleep disorders. Depression can occur in people who suffer from other brain disorders such as Parkinson's disease and Alzheimer's disease and usually occurs in people who have an anxiety disorder. People who have bipolar disorder experience cycles of depression and mania.
Anxiety is a common symptom of depression and depression is often associated with anxiety. In fact, approximately 42% of people with depression reported symptoms of worry, psychic anxiety and somatic anxiety of at least moderate severity in a 1983 survey (Fawcett and Kravitz, 1983).
Anxiety syndromes and their relationship to depressive illness Fawcett J, Kravitz HM - J Clin Psychiatry. 1983 Aug;44(8 Pt 2):8-11 - PMID: 6874657 The DSM-III categories of anxiety disorder are reviewed and a study of anxiety symptoms in subjects with RDC-defined major depression is described. Anxiety appears to be common in major depression : 29% of the sample studied had a history of panic attacks and moderate psychic anxiety was reported in 62%. Analysis by depressive subtypes showed no differences for the bipolar/unipolar distinction. However, significant differences in anxiety symptoms were seen in the primary vs. secondary and, more strikingly, endogenous vs. nonendogenous categories. The presence/severity of anxiety symptoms thus appears to be an important factor in the clinical management of major depression and may eventually serve as a guide to choosing among the increasing number of available antidepressant medications. Cfr. : http://www.ncbi.nlm.nih.gov/pubmed/6874657
Atypical depression – characterised by depression with significant anxiety, hyperphagia, hypersomnia, reverse diurnal variation and extreme reaction sensitivity – is particularly associated with anxiety in depression.
Hyperphagia bnormally increased appetite for and consumption of food, thought to be associated with a lesion or injury in the hypothalamus.
Hypersomnia The hypersomnias are a type of dyssomnia and are characterised by excessive deep sleep or a prolonged period of sleep. There are two main types of hypersomnia : sleep apnoea and narcolepsy. People with hypersomnias experience daytime sleepiness, irritability, headaches and impaired memory and concentration.
The efficacy of the selective serotonin reuptake inhibitors (SSRIs) in the treatment of both mood and anxiety disorders clearly demonstrates an overlap between the two.
Serotonin A neurotransmitter thought to be implicated in many brain disorders. The role of serotonin in depression and anxiety disorders is well established. Neurons containing serotonin are largely restricted to the midbrain although their axons branch out over much of the central nervous system.
Selective serotonin reuptake inhibitors (SSRIs) Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressants used in the treatment of depression, anxiety disorders and some personality disorders. They are also typically effective and used in treating premature ejaculation problems as well as some cases of insomnia. SSRIs increase the extracellular level of the neurotransmitter serotonin by inhibiting its reuptake into the presynaptic cell, increasing the level of serotonin available to bind to the postsynaptic receptor. They have varying degrees of selectivity for the other monoamine transporters, having little binding affinity for the noradrenaline and dopamine transporters. The first class of psychotropic drugs to be rationally designed, SSRIs are the most widely prescribed antidepressants in many countries.
Furthermore, a recent epidemiological study by the World Health Organization on the association between anxiety and depression (Sartorius et al, 1996) confirmed the association between the two disorders.
Depression comorbid with anxiety - Results from the WHO study on psychological disorders in primary health care Sartorius N, Ustün TB, Lecrubier Y, Wittchen HU, Department of Psychiatry, University of Geneva, Switzerland - Br J Psychiatry Suppl. 1996 Jun;(30):38-43 - PMID: 8864147 The World Health Organization collaborative study on "Psychological Problems in General Health Care" investigated the form, frequency, course and outcome of common psychological problems in primary care settings at 15 international sites. The research employed a two-stage case-finding procedure. GHQ-12 was administered to 25916 adults who consulted health-care services. The second-stage assessment (n = 5438) consisted of the Composite international Diagnostic Interview (CIDI), the Social Disability Schedule and questionnaires. Possible cases or borderline cases of mental disorder and a sample of known cases, were followed up at three months and one year. Using standard diagnostic algorithms (ICD-10), prevalence rates were calculated for current disorder (one-month) and lifetime experience disorder. Well-defined psychological problems are frequent in all the general health-care settings examined (median 24.0%). Among the most common were depression anxiety, alcohol misuse, somatoform disorders and neurasthenia. Nine per cent of patients suffered from a "subthreshold condition" that did not meet diagnostic criteria but had clinically significant symptoms and functional impairment. The most common co-occurrence was depression and anxiety. Comorbidity increases the likelihood of recognition of mental disorders in general health care and the likelihood of receiving treatment. Cfr. : http://www.ncbi.nlm.nih.gov/pubmed/8864147
Anxiety symptoms were more pronounced in the elderly and in patients with concomitant medical disease. Another authority (Liebowitz, 1993) confirms the co-occurrence of the two disorders and recommends that anxiety symptoms should be taken into account when assessing the most appropriate antidepressant agent for treating someone with depression, to optimise treatment outcome and recovery rate.
Depression with anxiety and atypical depression Liebowitz MR, Department of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, New York, N.Y. - J Clin Psychiatry. 1993 Feb;54 Suppl:10-4; discussion 15 - PMID: 8444829 Some forms of anxiety and affective disorder, such as panic disorder and major depression, appear distinct, but frequently symptoms of depression and anxiety occur together. The comorbidity of anxiety and depression not only has implications for the differential diagnosis of the disorder but affects the severity and course of illness and its responsiveness to treatment. The results of studies of atypical depression suggest that this form of depressive illness responds better to monoamine oxidase inhibiting medications than to tricyclic antidepressant agents and this preferential responsiveness may in fact define the boundaries of atypical depression. The serotonin selective reuptake inhibitor paroxetine seems to have a beneficial effect on symptoms of anxiety and agitation in depressed patients. Further clinical research is needed, however, to determine the best way to manage depression with anxiety and atypical depression. Cfr. : http://www.ncbi.nlm.nih.gov/pubmed/8444829
People with depression who have high anxiety levels take significantly longer to recover, have a higher rate of multiple drug treatments, a higher incidence of suicide and more frequent episodes of depression than people with depression who have no symptoms of anxiety (Joffe, 1993; Angst, 1997).
Toward validation of atypical depression in the community - Results of the Zurich cohort study Jules Angst - Journal of Affective Disorders, Volume 72, Issue 2, Pages 125 – 138 Aims - This paper (1) examines the validity of the atypical subtype of depression in a community-based longitudinal cohort study, (2) presents estimates of the prevalence and sex differences of DSM-IV atypical depression and a newly more broadly defined atypical syndrome in the community and (3) compares the clinical correlates and treatment patterns of those with atypical depression with other depressives. Methods - The Zurich cohort study is comprised of 591 subjects selected from a population-based cohort of young adults representative of the canton of Zurich in Switzerland, who were screened in 1978 with the Symptom Checklist 90-R [L.R. Derogatis (1977)] and followed prospectively with five interviews between 1979 and 1993. Atypical depression was defined on a spectrum ranging from atypical major to minor to atypical depressive symptoms alone. Results - The rate of DSM-IV atypical major depressive episodes in this community is 4.8% and for major atypical depression syndrome is 7.3%. Whereas there was no marked sex difference for nonatypical features, there was a significant female preponderance for DSM-IV and broadly defined atypical depressive subtypes. Systematic investigation of the diagnostic criteria for atypical depression revealed that a nonhierarchical definition of atypical depression with respect to mood reactivity yielded as valid a syndromic definition as the current hierarchy based on mood reactivity as an essential feature. Very high comorbidity (odd ratios>2.0) was found with seasonality, bipolar II, social phobia, binge eating, neurasthenia and sociopathy. Limitations - Atypical depression was not defined à priori, its criteria were derived from two sections of the Zurich interview. Conclusions - Atypical depression has high population prevalence and substantial significance in terms of clinical severity, impairment and service use. The intriguing finding that the sex difference in depression may be attributed to atypical features of depression will need further investigation. Overall, our data indicate that the atypical subtype of depression is a valid entity based on evidence from such traditional indicators of validity as inclusion criteria and indicators of course. However, there are some problems with discriminatory validity from other disorders. Although comorbidity with these disorders may in part reflect an operational artifact of symptom overlap, further work needs to be done in distinguishing atypical depression from bipolar II. Cfr. : http://linkinghub.elsevier.com/retrieve/pii/S0165032702001696
The precise relationship between depression and anxiety disorders is still to be fully established. Anxiety is not a requirement for the diagnosis of major depression (DSM-IV, 1994; ICD-10, 1992) and mood and anxiety disorders are recognised as distinctly separate diseases.
Diagnostic and Statistical Manual of Mental Disorders DSM-IV American Psychiatric Association, Washington, DC, 1994 Cfr. : http://nl.wikipedia.org/wiki/DSM-IV Cfr. also the text revision of this manual : Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR American Psychiatric Association, Washington, DC (4th ed.), Janauary 2000 Since the DSM-IV was published in 1994, we've seen many advances in our knowledge of psychiatric illness. This Text Revision incorporates information culled from a comprehensive literature review of research about mental disorders published since DSM-IV was completed in 1994. Updated information is included about the associated features, culture, age and gender features, prevalence, course and familial pattern of mental disorders. The DSM-IV-TR brings this essential diagnostic tool up-to-date, to promote effective diagnosis, treatment and quality of care. Now you can get all the essential diagnostic information you rely on from the DSM-IV along with important updates not found in the 1994 edition. Stay current with important updates to the DSM-IV-TR : -benefit from new research into Schizophrenia, Asperger's Disorder and other conditions - utilize additional information about the epidemiology and other facets of DSM conditions - update ICD-9-CM codes implemented since 1994 (including 'Conduct Disorder', 'Dementia' & 'Somatoform Disorders') Cfr. : http://www.bol.com/nl/p/boeken-engels/diagnostic-and-statistical-manual-of-mental-disorders-dsm-iv-tr/1001004001341827/index.html
International Statistical Classification of Diseases (and Related Health Problems) – ICD-10 The International Statistical Classification of Diseases and Related Health Problems (ICD-10) was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States as from 1994. The classification is the latest in a series which has its origins in the 1850s. The first edition, known as the 'International List of Causes of Death', was adopted by the International Statistical Institute in 1893. WHO took over the responsibility for the ICD at its creation in 1948 when the Sixth Revision, which included causes of morbidity for the first time, was published. The World Health Assembly adopted in 1967 the WHO Nomenclature Regulations that stipulate use of ICD in its most current revision for mortality and morbidity statistics by all Member States. The ICD is the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines. It is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and health records. In addition to enabling the storage and retrieval of diagnostic information for clinical, epidemiological and quality purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States. Cfr. : http://www.who.int/classifications/icd/en/ Cfr. also : - History of the development of the ICD cfr. : http://www.who.int/classifications/icd/en/HistoryOfICD.pdf - International Statistical Classification of Diseases and Related Health Problems, 10th Revision - Version for 2007 Cfr. : http://www.who.int/classifications/apps/icd/icd10online/ - Implementation of ICD Cfr. : http://www.who.int/classifications/icd/implementation/en/index.html
However, the question of a continuum has never been completely abandoned and a group of ‘in-between’ patients, with symptoms of both anxiety and depression, has been described (Angst, 1997).
Depression–anxiety relationships with chronic physical conditions - Results from the World Mental Health surveys (cfr. above)
2. - Bipolar Disorders
Bipolar disorder Bipolar disorder is a type of mood disorder. It is also known as bipolar depression or manic depression. The illness is characterised by cycles of mania and depression which cause a person with bipolar disorder to experience severe mood swings. There are three types of bipolar disorder : type I, type II and cyclothymia.
The Stanley Foundation Bipolar Network reports a high percentage of concomitant psychiatric conditions with bipolar disorder. Panic disorder, social phobia, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and impulse control disorders (eg pathologic gambling, kleptomania) often present concurrently with bipolar disorder (NIMH, 2000; Suppes et al, 2000).
Panic disorder People who suffer from panic disorder experience repeated episodes of intense fear that strike often and without warning. These are panic attacks. Physical symptoms include palpitations, sweating, trembling, chest pain, nausea, dizziness and hot flushes.
Social phobia People with social phobia have an overwhelming and disabling fear of scrutiny, embarrassment or humiliation in social situations, which causes them to avoid many potentially pleasurable and important activities.
Stress A series of physiological or behavioural responses to an environmental or perceived threat. These responses can include numbing of emotion, depression, anger, irritability and loss of concentration. The term 'stress' is also used to refer to the stimuli that elicit these reactions.
Obsessive-compulsive disorder (OCD) A type of anxiety disorder causing the sufferer to experience repeated, unwanted thoughts or compulsive behaviours that seem impossible to stop or control.
Goals for research on bipolar disorder - The view from the National Institute of Mental Health (NIMH) Hyman SE, National Institute of Mental Health, Bethesda, MD 20892-9669, USA - Biol Psychiatry. 2000 Sep 15;48(6):436-41 - PMID: 11018216 We have much yet to accomplish in research on bipolar disorder. We must find vulnerability genes. We must identify the circuits that regulate mood, emotion, energy and other relevant functions that are affected in bipolar disorder and we must determine what goes wrong in those circuits during mania, depression and other aspects of this illness. We will need to translate findings in basic neuroscience, genetics and basic behavioral science into diverse clinical applications : novel treatments, diagnostic tools, epidemiologic approaches that could lead to preventive interventions and surrogate markers for clinical trials. We must develop improved psychosocial interventions and test both pharmacologic and psychosocial treatments in trials that, simultaneously, improve the quality of care available and convince insurers and employers that these treatments are of substantial benefit and cost effective. The agenda is ambitious, but entirely feasible, given the scientific tools and technologies that are currently available or on the horizon. The National Institute of Mental Health is newly recommitted to harnessing these tools and technologies for the benefit of people with bipolar disorder. Cfr. : http://www.ncbi.nlm.nih.gov/pubmed/11018216
The longitudinal course of bipolar disorder Suppes T, Dennehy EB, Gibbons EW, Department of Psychiatry, University of Texas, Southwestern Medical Center, Dallas 75390-9070, USA - J Clin Psychiatry. 2000;61 Suppl 9:23-30 - PMID: 10826657 Course of illness is central to our focus on bipolar disorder due to the lifelong nature of this illness in the majority of patients. In this overview, we highlight areas of consensus and debate on factors that impact course of illness. Findings on age at onset, psychiatric comorbidity, frequency of episodes, cycle pattern, rapid cycling, mixed symptoms, and precipitants of episodes including use of substances and antidepressants and lithium discontinuation are discussed. The diversity and range of presentation and even course of illness become quickly apparent in this review. Highlighting these factors rather than seeking a unifying theory should be a productive way to refine our ability to identify additive factors contributing to course of illness for patients with bipolar disorder. Cfr. : http://www.ncbi.nlm.nih.gov/pubmed/10826657?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed _DefaultReportPanel.Pubmed_RVDocSum
The National Institute of Mental Health (NTMH) recently reported an especially high incidence of PTSD and OCD in people with bipolar disorder, with 43% of people with bipolar disorder exhibiting symptoms of PTSD.
3. - Suicide
Severe anxiety may be a risk factor for suicide (Fawcett and Kravitz, 1983; Fawcett, 1997).
Anxiety syndromes and their relationship to depressive illness Fawcett J, Kravitz HM - J Clin Psychiatry. 1983 Aug;44(8 Pt 2):8-11 - PMID: 6874657 The DSM-III categories of anxiety disorder are reviewed and a study of anxiety symptoms in subjects with RDC-defined major depression is described. Anxiety appears to be common in major depression : 29% of the sample studied had a history of panic attacks and moderate psychic anxiety was reported in 62%. Analysis by depressive subtypes showed no differences for the bipolar/unipolar distinction. However, significant differences in anxiety symptoms were seen in the primary vs. secondary and, more strikingly, endogenous vs. nonendogenous categories. The presence/severity of anxiety symptoms thus appears to be an important factor in the clinical management of major depression and may eventually serve as a guide to choosing among the increasing number of available antidepressant medications. Cfr. : http://www.ncbi.nlm.nih.gov/pubmed/6874657?dopt=Abstract
The detection and consequences of anxiety in clinical depression Fawcett J, Department of Psychiatry, Rush-Presbyterian-St. Luke's Medical Centre, Chicago, IL 60612-3824, USA J Clin Psychiatry. 1997;58 Suppl 8:35-40 - PMID: 9236734 Anxiety symptoms and comorbid anxiety are common in depressive syndromes and there is evidence they are associated with increased severity of depression and a poorer outcome. Anxiety and agitation symptoms also appear to be an acute risk factor for suicide in patients who have major affective disorder, an observation that has been supported by a number of biological correlates. Rapid and aggressive treatment of these anxiety/agitation symptoms with suitable antidepressants or benzodiazepines should be considered in order to avoid the immediate risk of suicide and to permit successful treatment of the affective disorder. Cfr. : http://www.ncbi.nlm.nih.gov/pubmed/9236734
Studies have reported that a significant number of people who committed suicide were diagnosed as having an anxiety disorder (Allebeck, 1988) and a significantly increased suicide rate is seen in people with panic disorder (Coryell, 1988).
Predictors of completed suicide in a cohort of 50,465 young men - Role of personality and deviant behaviour Allebeck P, Allgulander C, Fisher LD, Karolinska Institute, Huddinge University Hospital, Sweden - BMJ. 1988 Jul 16;297(6642):176-8 - PMID: 3408955 Suicide seems to be increasing in young people in various countries and causes the greatest loss of years of life under the age of 65 in the Swedish population. Data from a national survey of 50,465 conscripts in Sweden were used in a prospective follow up study to assess personality and behavioural predictors of suicide in young men. Altogether 247 completed suicides occurred in the cohort during 13 years' follow up. Baseline data on social conditions, psychological assessments and psychiatric diagnoses of the conscripts were entered into a Cox regression model with suicide as the outcome variable. Several early indicators of antisocial personality (poor emotional control, contact with a child welfare authority or the police and lack of friends) were strongly predictive of suicide. None of the few conscripts who had a diagnosis of schizophrenia or affective psychosis committed suicide. A diagnosis of neurosis was associated with a twofold increase in the suicide rate and personality disorder with a threefold increase. Although the risk of suicide is difficult to assess in an unselected population owing to the low base rate of suicide, the predictors identified in the study may help to identify those at high risk in units where people with deviant behaviour and personality disorders cluster. Cfr. : http://www.ncbi.nlm.nih.gov/pubmed/3408955
Panic disorder and mortality Coryell W, Department of Psychiatry, University of Iowa, Iowa City - Psychiatr Clin North Am. 1988 Jun;11(2):433-40 - PMID: 3047710 Evidence so far indicates two sources for excess mortality in panic disorder--suicide and cardiovascular morbidity. The risk for eventual suicide may rival that for primary depression, but the predictors and the necessary antecedents probably differ. The lapse between diagnosis and suicide may be larger for panic disorder, and complications such as secondary depression and substance abuse may be necessary. There are few well-established predictors for primary depression despite many relevant studies. The risk for suicide in panic disorder is barely recognized and established predictors are accordingly remote. One study has demonstrated excess cardiovascular mortality among males with panic disorder and another from the same center has provided weak support. Only one additional study has provided the necessary detail as to sex and cause and those findings were quite supportive, although the subjects may have been mixed diagnostically. There are numerous feasible explanations for excess cardiovascular mortality in panic disorder and even some reason to believe that successful treatment might lessen it. To so advise patients would be not only premature at this point but unnecessary and countertherapeutic--unnecessary because these patients are motivated by discomfort to seek treatment and countertherapeutic because cardiovascular morbidity is what many of these patients pathologically fear. Rather, the findings suggest focus for future study. The initial findings of excess cardiovascular morbidity in males badly need replication, as do the more recent findings of Kahn et al. Likewise, animal models may reveal some of the pathophysiologic mechanisms at work. It is hoped that these efforts will converge in the not-too-distant future.
A study in Finland investigating the role of anxiety as a comorbid diagnosis found that over a period of 1 year, 17% of people who committed suicide were diagnosed retrospectively as having depression with a comorbid anxiety disorder and 6% had bipolar disorder with a comorbid anxiety disorder (Isometsä, 1994).
In a prospective study by Fawcett et al. (1990), also investigating the comorbidity of anxiety and suicide, the role of the anxiety symptoms in suicide was clarified. Fawcett et al concluded that suicidal ideation, a history of past suicide attempts and the severity of hopelessness did not correlate significantly with suicide, whereas the severity of psychic anxiety and the presence of panic attacks did show a significant correlation with suicide.
Further studies by this team confirmed the important role of severe psychic anxiety 1 week before suicide (Fawcett, 1997).
The detection and consequences of anxiety in clinical depression (cfr. above)
It is known that serotonin dysfunction has a role in both suicide and anxiety. Furthermore, a number of biological markers, such as markers of the hypothalamo–pituitary–adrenal axis and serotonin function, appear to be associated with both anxiety and suicide risk in depression. Dysfunction in the hypothalamo–pituitary–adrenal axis and the serotonin system may be associated with states of overwhelming anxiety-agitation and decisive treatment to correct the dysfunction seems to resolve this crisis and allow successful resolution of the episode.
However, little attention is given to the role of anxiety in suicide in clinical practice and the potential for suicide is often not considered when planning treatment regimens for people with anxiety disorders.
With headlines warning us of international terrorism, global warming and economic slowdown, we're all likely to be a little more anxious these days. As an everyday emotion, anxiety — the "fight or flight" response — can be a good thing, prompting us to take extra precautions. But when anxiety persists in the absence of a need to fight or flee, it can not only interfere with our daily lives but also undermine our physical health. Evidence suggests that people with anxiety disorders are at greater risk for developing a number of chronic medical conditions. They may also have more severe symptoms and a greater risk of death when they become ill.
The Anatomy of Anxiety
Anxiety is a reaction to stress that has both psychological and physical features. The feeling is thought to arise in the amygdala, a brain region that governs many intense emotional responses. As neurotransmitters carry the impulse to the sympathetic nervous system, heart and breathing rates increase, muscles tense and blood flow is diverted from the abdominal organs to the brain. In the short term, anxiety prepares us to confront a crisis by putting the body on alert. But its physical effects can be counterproductive, causing light-headedness, nausea, diarrhea and frequent urination. And when it persists, anxiety can take a toll on our mental and physical health.
Anxiety as Illness
Research on the physiology of anxiety-related illness is still young, but there's growing evidence of mutual influence between emotions and physical functioning. Yet anxiety often goes unidentified as a source of other disorders, such as substance abuse or physical addiction, that can result from attempts to quell feelings of anxiety. And it's often overlooked in the myriad symptoms of chronic conditions like irritable bowel syndrome (IBS) or migraine headache.
Nearly two-thirds of the estimated 57 million adults with anxiety disorders are women. What people with these disorders have in common is unwarranted fear or distress that interferes with daily life (cfr. below). Anxiety also plays a role in somatoform disorders, which are characterized by physical symptoms such as pain, nausea, weakness or dizziness that have no apparent physical cause. Somatoform disorders include hypochondriasis, body dysmorphic disorder, pain disorder and conversion disorder.
Anxiety has now been implicated in several chronic physical illnesses, including heart disease, chronic respiratory disorders and gastrointestinal conditions. When people with these disorders have untreated anxiety, the disease itself is more difficult to treat, their physical symptoms often become worse and in some cases they die sooner.
Anxiety disorders and their symptoms
Generalized anxiety disorder Exaggerated worry about health, safety, money and other aspects of daily life that lasts six months or more. Often accompanied by muscle pain, fatigue, headaches, nausea, breathlessness and insomnia.
Phobias Irrational fear of specific things or situations, such as spiders (arachnophobia), being in crowds (agoraphobia) or being in enclosed spaces (claustrophobia).
Social anxiety disorder (social phobia) Overwhelming self-consciousness in ordinary social encounters, heightened by a sense of being watched and judged by others and a fear of embarrassment.
Post-traumatic stress disorder (PTSD) Reliving an intense physical or emotional threat or injury (for example, childhood abuse, combat or an earthquake) in vivid dreams, flashbacks or tormented memories. Other symptoms include difficulty sleeping or concentrating, angry outbursts, emotional withdrawal and a heightened startle response.
Obsessive/compulsive disorder (OCD) Obsessive thoughts, such as an irrational fear of contamination, accompanied by compulsive acts, such as repetitive hand washing, that are undertaken to alleviate the anxiety generated by the thoughts.
Panic disorder Recurrent episodes of unprovoked feelings of terror or impending doom, accompanied by rapid heartbeat, sweating, dizziness or weakness.
Anxiety and Gastrointestinal Disorders
About 10% to 20% of Americans suffer from the two most common functional digestive disorders — IBS and functional dyspepsia (upset stomach). In these disorders, the nerves regulating digestion appear to be hypersensitive to stimulation. Because these conditions don't produce lesions like ulcers or tumors, they aren't considered life-threatening. But their symptoms — abdominal pain, bloating and diarrhea or constipation in IBS and pain, nausea and vomiting in functional dyspepsia — can be chronic and difficult to tolerate.
There are no firm data on the prevalence of anxiety disorders in people with functional digestive disorders, but a 2007 New Zealand study of subjects with gastroenteritis (inflammation of the digestive tract) found an association between high anxiety levels and the development of IBS following a bowel infection.
Chronic Respiratory Disorders
In asthma, inflamed airways constrict spasmodically, reducing the flow of air through the lungs. In chronic obstructive pulmonary disease (COPD), inflammation of the airways is exacerbated by a loss of elasticity in the lungs : not only is it more difficult for air to reach the lungs, but the lungs neither fill nor expel air completely.
Although results vary, most studies have found a high rate of anxiety symptoms and panic attacks in patients who have chronic respiratory disease, with women at greater risk than men. In several studies involving COPD patients, anxiety has been associated with more frequent hospitalization and with more severe distress at every level of lung function. So even if anxiety doesn't affect the progress of the disease, it takes a substantial toll on quality of life.
Anxiety and Heart Disease
Anxiety disorders have also been linked to the development of heart disease and to coronary events in people who already have heart disease. In the Nurses' Health Study, women with the highest levels of phobic anxiety were 59% more likely to have a heart attack and 31% more likely to die from one, than women with the lowest anxiety levels. Data from 3,300 postmenopausal women in the Women's Health Initiative showed that a history of full-blown panic attacks tripled the risk of a coronary event or stroke.
Two studies — one involving Harvard Medical School and the Lown Cardiovascular Research Institute; the other, several Canadian medical colleges — concluded that among both men and women with established heart disease, those suffering from an anxiety disorder were twice as likely to have a heart attack as those with no history of anxiety disorders.
Physical Benefits of Treating Anxiety
Therapies that have been successful in treating anxiety disorders are now being used to ease the symptoms of chronic gastrointestinal and respiratory diseases. These therapies may have an important role in preventing and treating heart disease. These are the best-studied approaches :
Cognitive-behavioral therapy The cognitive component helps people identify and avoid thoughts that generate anxiety and the behavioral part helps them learn how to react differently to anxiety-provoking situations. The specifics of the treatment depend on the type of anxiety. For example, patients with generalized anxiety disorder or panic disorder may be asked to examine their lives for habits and patterns that foster a sense of dread. They may also be taught relaxation techniques to diminish anxiety. Patients with OCD characterized by excessive washing may be asked to dirty their hands and wait with a therapist for increasingly longer intervals before cleaning up.
Psychodynamic psychotherapy Anxiety is often triggered by a deep-seated emotional conflict or a traumatic experience that can sometimes be explored and resolved through psychotherapy. In the first randomized controlled clinical trial comparing relaxation therapy to psychodynamic psychotherapy (focused talk therapy), clinician-researchers at Columbia University in New York found that panic-disorder patients treated with psychodynamic therapy had significantly fewer symptoms and functioned better socially than those who underwent relaxation therapy (American Journal of Psychiatry, February 2007). Nearly three-quarters of the psychotherapy group responded to treatment compared with only 39% of the relaxation-therapy group.
Medications alone are less effective than psychotherapy over the long term; they may also have unpleasant side effects and interact with other medications. Still, they can be helpful when used in combination with psychotherapy. The most commonly used types of drugs include these :
Anti-anxiety drugs Benzodiazepines — clonazepam (Klonopin) and alprazolam (Xanax) — were developed to relieve anxiety. They act rapidly and have few side effects except occasional drowsiness. But they're not recommended for long-term use, because patients develop tolerance and require increasing doses. A newer drug, buspirone (BuSpar), needs two weeks to take effect but can be taken for longer periods than benzodiazepines.
Antidepressants Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) such as sertraline (Zoloft), have been replacing benzodiazepines in the long-term treatment of panic disorder and generalized anxiety. Antidepressants have the advantage of relieving depression as well as anxiety and they are believed to create less risk of dependence and abuse. However, patients sometimes prefer benzodiazepines to antidepressants because they act more quickly (antidepressants take two weeks to work) and don't cause weight gain or sexual problems.
Beta blockers These drugs can relieve acute anxiety by slowing the heart rate and reducing blood pressure; they are often used, for example, to treat stage fright.
About 30% of people with anxiety disorders go through life untreated. If you think you might fall into this category — or if you have IBS, asthma, COPD or heart disease and haven't been evaluated for anxiety — you may want to consult your primary care clinician. You may also want to talk to your clinician if you have pain, dizziness, insomnia or other symptoms that persist after physical causes have been ruled out. Keep in mind that all symptoms are real — and treatable — whether they originate in the body or the brain. If you're just feeling a little more anxious than you once did, you might want to consider trying some relaxation techniques (for some examples, visit : www.health.harvard.edu/womenextra -).
While agreement is growing that mental illness burdens the North American economy, how it impacts productivity particularly compared to physical illness is unclear. Hypothesizing that lost work days are only the tip of the iceberg, we also examined the association of mental and chronic physical illness with partial work days and days requiring extra effort to function. Data from 4225 employed individuals, aged 18-54, were analyzed. These were a subset of respondents to the Ontario Health Survey's Mental Health Supplement, a 1990/91 epidemiologic survey of households across Ontario, Canada. Psychiatric disorder was assessed using the University of Michigan' modification of WHO's Composite International Diagnostic Interview (UM-CIDI). Similar to US reports, professional/managerial groups had lower rates of affective and anxiety disorders and fewer disability days compared to the rest of the workforce. However, no single occupational group was consistently at greater risk for either physical or psychiatric problems. Even after accounting for sociodemographic characteristics and work conditions, mental and physical status had clear, but different, impacts on productivity. Physical conditions alone had a fairly constant effect across all types of disability days and were the largest contributor to total work day loss. They also significantly impacted partial and extra effort days but were far less important than conditions involving a mental disorder. Respondents with mental health problems, either alone or in combination with physical illnesses, appeared more likely to go to work hut to require greater effort to function. WHO projects that mental illness will become the second most important cause of global disease burden in the next century. Our findings suggest that among working individuals, it affects productivity more subtly than does physical illness. However, with an estimated eight percent of Ontario's workforce experiencing more than two months annually of decreased productivity, it still incurs significant social and economic costs.
Jasper A. J. Smits, Michael J. Zvolensky – Springer Verlag, 11/07/2007 – ISBN : 9780387747521
Table of Contents
Part I. - Health Behaviors and Anxiety Disorders
Tobacco Use and Panic Psychopathology - Current Status and Future Directions Michael J. Zvolensky, Theresa Leyro, Amit Bernstein, Matthew T. Feldner, Andrew R. Yartz, Kimberly Babson and Marcel O. Bonn-Miller
Alcohol Use and Anxiety Disorders Brigitte C. Sabourin and Sherry H. Stewart
Illicit Drug Use Across the Anxiety Disorders - Prevalence, Underlying Mechanisms and Treatment Matthew T. Tull, David E. Baruch, Michelle S. Duplinsky and C.W. Lejuez
The Promise of Exercise Interventions for the Anxiety Disorders Jasper A. J. Smits, Angela C. Berry, Mark B. Powers, Tracy L. Greer and Michael W. Otto
Anxiety and Insomnia - Theoretical Relationship and Future Research Thomas W. Uhde and Bernadette M. Cortese
Part II. - Physical Conditions and Anxiety Disorders
Anxiety Disorders and Physical Illness Comorbidity - An Overview Tanya Sala, Brian J. Cox and Mender Sareen
The Relation Between Puberty and Adolescent Anxiety - Theory and Evidence Ellen W. Leen-Feldner, Laura E. Reardon, Chris Hayward and Rose C. Smith
Anxiety, Anxiety Disorders and the Menstrual Cycle Sandra T. Sigmon and Janell G. Schartel
Pain and Anxiety Disorders Gordon J.G. Asmundson, Murray P. Abrams and Kelsey C. Collimore
Asthma in Anxiety and Its Disorders - Overview and Synthesis Lisa S. Elwood and Bunmi O. Olatunji
Cardiovascular Disease and Anxiety Kamila S. White
HIV and Anxiety Conall O'Cleirigh, Trevor A. Hart and Carolyn A. James
Physical Illness and Treatment of Anxiety Disorders - A Review Norman B. Schmidt, Meghan E. Keough, Lora Rose Hunter and Ann P. Funk
The relationship between anxiety disorders and physical disorders in the U.S. - National Comorbidity Survey Sareen J, Cox BJ, Clara I, Asmundson GJ.. Depress Anxiety 2005; 21(4): 193-202 - Wiley-Liss, New York, NY, Etats-Unis, (Revue), 1996 - Depression and anxiety, 2005, vol. 21, no4, pp. 193-202 – ISSN 1091-4269 Although depression has clearly been shown to be associated with physical disorders, few studies have examined whether anxiety disorders are independently associated with medical conditions after adjusting for comorbid mental disorders. We examined the relationship between anxiety disorders and a wide range of physical disorders in a nationally representative sample. Data came from the National Comorbidity Survey (N=5,877, range=age 15-54 years, response rate=82.4%). The Composite International Diagnostic Interview [Kessler et al., 1998] was used to make DSM-III-R [American Psychiatric Association, 1987] mental disorder diagnoses. Physical disorders were assessed based on a list of several conditions shown to respondents. All analyses utilized multiple logistic regression to examine the relationship between past-year anxiety disorder diagnosis and past-year chronic physical disorder. Anxiety disorders were positively associated with physical disorders even after adjusting for mood disorders, substance-use disorders and sociodemographics. Among respondents with one or more physical disorders, a comorbid anxiety disorder diagnosis was associated with an increased likelihood of disability even after adjusting for severity of pain, comorbid mood and substance use disorders. Among specific anxiety disorders, posttraumatic stress disorder, panic attacks and agoraphobia were more likely to be associated with specific physical disorders than generalized anxiety disorder, social phobia or simple phobia. There is a strong and unique association between anxiety disorders and physical disorders. Clinically, the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability. Cfr. : http://cat.inist.fr/?aModele=afficheN&cpsidt=17029420
Den Haag - Het kabinet steekt ruim 400 miljoen euro in de reparatie van de koopkracht voor chronisch zieken, gehandicapten en minima. Volgens ingewijden wordt er onder meer geld uitgetrokken voor een hogere zorgtoeslag voor alleenstaanden met een minimuminkomen.
Dat is de uitkomst van overleg tussen de fractievoorzitters van de coalitiepartijen CDA, PvdA en ChristenUnie en minister Piet Hein Donner (Sociale Zaken) en staatssecretaris Jet Bussemaker (Volksgezondheid) over de buitengewone zorgkosten. Aanleiding is de aangekondigde bezuiniging op de fiscale compensatieregeling voor buitengewone zorgkosten, waardoor vooral chronisch zieken en gehandicapten erop achteruit dreigen te gaan.
Om de gevolgen voor hun portemonnee te verzachten gaan tegemoetkomingen waarop chronisch zieken straks recht hebben omhoog. Ook komt er een hogere toeslag voor arbeidsongeschikten. Chronisch zieken en gehandicapten mochten hun zorgkosten meer dan verdubbelen voor ze die gingen aftrekken. Het kabinet wilde hiervan af, maar laat dit toch deels in stand. Naast de hogere zorgtoeslag, steekt het kabinet ook nog geld in een ruimere ouderenkorting.
Coalitiepartij PvdA is tevreden met de uitkomsten. Er zijn nog laatste berekeningen nodig, maar PvdA-fractievoorzitter Mariëtte Hamer zei maandag na overleg tussen de coalitiepartijen en het kabinet dat ‘het de goede kant uit gaat’. GroenLinks wil dinsdag in het wekelijkse vragenuur opheldering over het coalitieberaad.
De aanpassingen waar het kabinet nu mee komt betreffen de nieuwe wet voor tegemoetkomingen voor chronisch zieken en gehandicapten. De bestaande fiscale compensatieregeling voor hoge zorgkosten wordt sterk afgeslankt. Deze wordt voor een groot deel vervangen door toeslagen voor chronisch zieken en gehandicapten, verlaging van eigen bijdragen voor AWBZ-zorg en een algemene compensatie voor ouderen en arbeidsongeschikten.
Den Haag - Voor de derde keer snijdt het kabinet in de tegemoetkoming voor kosten van chronisch zieken en gehandicapten. Een meevaller van 200 miljoen euro – gevolg van ingrepen in de fiscale tegemoetkoming voor designbrillen en verbanddozen – gaat niet terug naar chronisch zieken, maar wordt gebruikt om andere gaten op de begroting te dichten.
Bij de kabinetsformatie werd al 400 miljoen euro per jaar aan bezuinigingen ingeboekt op de ‘tegemoetkoming buitengewone uitgaven’, een fiscale aftrekpost bedoeld voor bijkomende ziektekosten als taxivervoer of aanpassing van de woning. In de praktijk bleek die regeling steeds meer oneigenlijk te worden gebruikt. Miljoenen Nederlanders trokken ziektekostenpremie, Armanibrillen en steunzolen af van de belasting.
Het kabinet besloot daarom tot een nieuwe regeling. Gehandicapten mochten er daarin niet op achteruitgaan. Tegelijkertijd moest een bezuiniging worden ingeboekt van 250 miljoen euro – die had het kabinet nodig voor gratis schoolboeken.
Het voorstel dat het kabinet voor de zomer naar de Kamer stuurde, bleek echter ook de gehandicapten te raken voor wie de aftrekpost wel was bedoeld. Het Nibud rekende voor dat de koopkracht van sommige chronisch zieken met 9 procent zou dalen. En dus gaf de Kamer het kabinet opdracht de regeling zo aan te passen dat de ergste gevolgen werden teruggedraaid. Het lijkt er nu op dat dat niet is gelukt. Op Prinsjesdag worden de plannen bekendgemaakt.
Directeur Ad Poppelaars van de Chronisch zieken en Gehandicapten Raad zegt ‘geschokt’ te zijn : ‘De zieken en gehandicapten draaien op voor het koopkrachtbehoud van de rest van Nederland.’ Hij gaat het Nibud nogmaals vragen in kaart te brengen wat de gevolgen zijn van de ingreep voor de koopkracht van mensen met een chronische aandoening.
Den Haag - Het grootste aantal werknemers dat gedeeltelijk wordt afgekeurd, werkt in de zorg. Omdat in de zorg veel mensen werken, wijkt het risico om arbeidsongeschikt te worden in de zorg niet af van het landelijk gemiddelde. Dit blijkt uit cijfers van het UWV :
Landelijk is het risico om arbeidsongeschikt te worden voor werknemers in vaste dienst 0,13 procent. Dat betekent dat van elke tienduizend werknemers er dertien deels worden afgekeurd.
In 2007 ging het om 9755 werknemers die deels werden afgekeurd. Daarnaast werden zevenduizend mensen afgekeurd die een tijdelijk contract hadden of werkloos waren. Vijfduizend werknemers zijn volledig afgekeurd, omdat zij geen uitzicht op herstel hebben. Het UWV geeft in de cijfers niet aan in welke sectoren zij werkten.
In de zorg werden in 2007 1657 werknemers deels afgekeurd, bijna eenvijfde van het totaal, 9755. Omdat er ruim 1,2 miljoen mensen in de zorg werken, is het risico op arbeidsongeschiktheid daar gelijk aan het landelijk gemiddelde.
Het risico op arbeidsongeschiktheid is het hoogst bij de reïntegratiebedrijven. Daar werden vorig jaar 352 mensen deels afgekeurd, ofwel 0,35 procent van de ruim honderdduizend werknemers.
Het UWV publiceert ook een lijst met het risico op arbeidsongeschiktheid bij bedrijven met meer dan 250 werknemers. Bij de reïntegratiebedrijven springt daar de gemeente Enschede eruit. Daar is het risico op arbeidsongeschiktheid 2,6 procent. Dat is het twintigvoudige van het landelijk gemiddelde.
Bij de grootwinkelbedrijven springt de Brilmij Groep eruit met een risico van 1,8 procent. Bij de overheid piekt de gemeente Lelystad met een risico voor ambtenaren op arbeidsongeschiktheid van 1,2 procent.
Ook drie FNV-bonden staan in de lijst. Bij de Abvakabo FNV is het risico om arbeidsongeschikt te worden 0,2 procent, bij FNV Bouw 0,3 procent en bij FNV Bondgenoten 0,1 procent.
Het risico op arbeidsongeschiktheid is sterk gedaald door de versobering van de arbeidsongeschiktheidswetten. Bij de oude arbeidsongeschiktheidswet WAO schommelde het risico afgekeurd te worden door de jaren heen rond 1,3 procent. Dat is door de strenge keuringseisen tot eentiende gedaald.
Den Haag - Wie in de zorg werkt maar daarmee stopt wegens kleine kinderen, moet ‘groot zorgverlof’ kunnen krijgen. Zoals vroeger, toen de dienstplicht nog bestond, militairen op herhaling geroepen konden worden, zouden verpleegsters op die manier een relatie met hun oude werkgever kunnen houden. Tussentijds zouden de (vooral vrouwelijke) werknemers bijscholing kunnen krijgen om snel weer aan de slag te kunnen als ze dat willen.
PvdA-staatssecretaris Ahmed Aboutaleb (Sociale Zaken) zei woensdag dat hij dit idee voor groot verlof bekijkt met collega en partijgenoot Jet Bussemaker (Volksgezondheid). De bewindslieden hopen op deze manier zowel de personeelstekorten in de zorg aan te pakken als een blijvend verlies van veel goed opgeleide vrouwen voor de arbeidsmarkt tegen te gaan.
Stoppen met werken begrijpelijk
Aboutaleb heeft er begrip voor dat vrouwen helemaal stoppen met werken, zolang hun kinderen nog niet naar de basisschool gaan. Hij vindt dat ze na die circa vier jaar een soort terugkeerrecht moeten kunnen krijgen bij hun oude werkgever als zij hun bekwaamheden bijhouden tijdens het groot verlof. Nu stuiten herintreedsters vaak op problemen om weer aan de slag te komen, omdat hun kennis verouderd is.
Groot verlof zou volgens Aboutaleb misschien ook een idee zijn voor het onderwijs. Hij wijst erop dat deze sector eveneens kampt met personeelstekorten en veel vrouwelijke werknemers kent.
Merijn Rengers & Xander van Uffelen – de Volkskrant, 28-08-2008
Amsterdam - Twintig van de honderd grootste zorginstellingen van Nederland betalen hun directeur meer dan 220 duizend euro, het maximum jaarinkomen dat de branche zelf voor ogen heeft. Zestig van de honderd zorgdirecteuren ontvingen in 2007 een salaris dat hoger lag dan dan de Balkenendenorm van 176 duizend euro. Dat blijkt uit een inventarisatie van de Volkskrant.
De grootverdieners zijn vooral werkzaam bij ziekenhuizen. Maar ook in de gehandicaptenzorg, de geestelijke gezondheidszorg en bij verzorgingstehuizen betalen instellingen hun directeuren boven de Balkenendenorm. Elf van de honderd instellingen heeft geen gegevens beschikbaar over salarissen.
Het Radboud Ziekenhuis uit Nijmegen betaalt zijn bestuursvoorzitter het hoogste bedrag. Emile Lohman, voorheen werkzaam bij het OLVG in Amsterdam, kreeg in 2007 een brutojaarsalaris van 290 duizend euro. De zorgsector lanceerde deze week een salarisnorm, waarbij zorginstellingen onder strikte voorwaarden maximaal 220 duizend euro bruto zouden mogen uitbetalen.
Voor instellingen waar geen marktwerking is, mag het salaris niet hoger zijn dan de Balkenendenorm van 176 duizend euro. De vereniging van toezichthouders in de zorg, één van de initiatiefnemers van de nieuwe beloningsregels, wil niet zeggen of de salarissen van zorgdirecteuren op korte termijn om laag zullen gaan. De vereniging wil niet reageren zolang de code nog ‘in ontwikkeling’ is.
Verplegersvakbond NU91 vindt zelfs de Balkenendenorm voor zorginstellingen veel te hoog. ‘Wat is er mis met de hoogste salarisschaal in de zorg van rond de 80 duizend euro ?’, zegt voorzitter Monique Kempff van NU91. Zij vindt het ‘geen argument’ dat voor dat salaris geen goede bestuurder is te vinden : ‘Voor de werkvloer zijn ook geen mensen te vinden. Krijgen die dan ook meer betaald ?’
Het gat tussen top en werkvloer is volgens Kempff veel te groot. De klachtenlijn van Nu91 staat roodgloeiend door telefoontjes van verontwaardigde thuiszorgmedewerkers. ‘Het personeel staat op straat, terwijl de mensen die verantwoordelijk zijn voor de puinhopen met tonnen naar huis gaan. Voor die bedragen kun je veel problemen in de organisatie oplossen.’
Merijn Rengers & Xander van Uffelen – de Volkskrant, 28-08-2008
Amsterdam - Het lijstje met naderende salarisverlagingen van bestuurders in de semi-publieke sector wordt gestaag langer. Na toezichthouder AFM, de Publieke Omroep en luchthaven Schiphol gaat nu ook een reeks van ziekenhuizen snijden in hun salarissen.
Tenminste, dat is het geval als de sector zijn eigen voornemens serieus neemt. Twintig van de honderd grootste zorginstellingen betalen hun directeur op dit moment meer dan het voorgestelde maximum bruto jaarsalaris van 220 duizend euro, blijkt uit een inventarisatie door De Volkskrant.
Als de nieuwe maximumnorm ingang vindt – daarover wordt volgende week in de Tweede Kamer gedebatteerd – zullen de zorginstellingen een groot aantal salarissen moeten inperken. Een deel van het parlement vindt dat de Balkenendenorm van 176 duizend euro voor álle zorginstellingen zou moeten gelden. Op dit moment krijgen zestig van de honderd directeuren meer betaald dan de premier.
Neem Philadelphia Zorg. Frits Brink, de voorzitter van de Raad van Bestuur van deze landelijk opererende stichting voor gehandicaptenzorg verdiende in 2007 een bruto salaris van 243 duizend euro – 23 duizend euro meer dan het voorgestelde maximum en bijna 70 duizend euro boven ‘Balkenende.’
Gaat Brink, die inmiddels ook zitting heeft genomen in de Raad van Bestuur van de overkoepelende zorggigant Espria salaris inleveren ? ‘Het gemeenschappelijke voorstel van de branche-organisaties NVZD en NVTZ wordt voorgelegd aan de leden. Die zullen het bestuderen en dan pas kunnen we reageren,’ is alles wat een woordvoerder daarover kwijt wil.
De leiding van Ipse De Bruggen, een andere, recent gefuseerde zorginstelling voor gehandicapten in Zuid-Holland is veel stelliger. In 2007 ontving interim-bestuursvoorzitter Adriaan van Belzen van het toen nog zelfstandige De Bruggen 287 duizend euro. ‘Dat was een honorarium voor een tijdelijke klus,’ zegt een woordvoerster : ‘We zijn inmiddels gefuseerd. De huidige voorzitter is gewoon in dienst en houdt zich aan de normen. Daar hecht hij zeer aan.’
Veel zorginstellingen vinden dat een weinig aanlokkelijk perspectief. Het openbreken van bestaande arbeidscontracten is vrijwel onmogelijk, redeneren zij. En de salarissen die momenteel betaald worden, waren ooit noodzakelijk om geschikte kandidaten te vinden.
Dat is ook het verhaal van het Haga Ziekenhuis in Den Haag. Directeur Chiel Huffmeijer, die in 2007 bruto 235 duizend euro verdiende, kwam daar in dienst toen het gefuseerde ziekenhuis in de problemen zat. ‘De zorgelijke situatie vroeg destijds om een zwaar gekwalificeerde bestuurder, voor wie een behoorlijk afbreukrisico gold. Een hogere honorering was dan ook alleszins te billijken. Het salaris is door de tijd geïndexeerd en het zou niet rechtvaardig dit nu terug te draaien,’ zegt een woordvoerder.
Op de werkvloer heerst vaak een heel ander sentiment. Niet zozeer onder de doktoren en medisch specialisten, die in sommige gevallen meer verdienen dan de bestuursvoorzitter het ziekenhuis waar zij werken. Maar wel onder verplegers en het personeel in bijvoorbeeld de gehandicaptenzorg en de psychiatrie. Die spiegelen zich aan de situatie in de thuiszorg. Daar zijn de gevolg van de marktwerking in de gezondheidszorg vanuit het personeel bezien hoekig : de salarissen van de thuiszorgdirecteuren zijn fors gestegen, terwijl de arbeidsvoorwaarden van het thuiszorgpersoneel onder druk staan.