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By Cretien van Campen

Frail older people are more oftentimes considered a burden for society, than not. They are perceived to require intensive care that can be expensive while producing nothing contributory to society. The collective image is that frail older people are ‘useless’. In my opinion, we do not endeavor to ‘use’ them or know how to release productivity in them.

Around the age of 70, the extremely frail wheelchair bound musician Johnny Cash made the music video ‘Hurt’ with the help of film director Mark Romanek and producer Rick Rubin. The video was a tremendous success, receiving abundant critical acclaim and becoming a favorite with many for all time. The song was taken from a series of albums, the ‘American Recordings’, Cash created in his frailest period, selling millions of copies. The albums have been regarded as outstanding contributions to American culture and many people have found strength, joy and solace in his recordings.

Click here to view the embedded video.

Cash was no exception. He was not the only frail older person who flourished in his last years. The painter Henri Matisse, the music conductor Herbert von Karajan, and others reached creative summits in the last seasons of their lives. Also non-artists like sawmill worker Lester Potts became a creative painter in his later years when he was suffering from Alzheimer’s disease. In other types of dementia, such as frontotemporal dementia, creativity can be released as well.

The case of Cash also is an example of what is needed to release creative productivity in a frail older person — and what has to be avoided. In his last years Cash suffered from several complex diseases and physical limitations, a long and sad process which biographer Robert Hilburn has described with compassion and in detail. Cash was successively diagnosed among others with Parkinson’s disease, Shy-Drager syndrome, and double pneumonia. These contributed to hospital admissions several times a year and receiving prescriptions in quantities that greatly impacted the long time Dexedrine (speed) addict. (Cash had been addicted during his career as a touring artist.)

By the end of the twentieth century Cash was in forlorn condition, exhausting himself in a mixture of drugs and over-extended tours. Of deeper emotional consequence, his records did not sell the numbers they once had. His musical career was considered by many to be over by the time he was approached by producer Rick Rubin. In retrospect Rubin gave Cash two ingredients that supported his creative productivity: mental reminiscences and physical exercises.

In elongated sessions at home Rubin and Cash played old and new music, evoking reminiscences with musical roots and connecting them with the music of younger generations, which created new flourish and renewed hunger for music in Cash. He transformed from an older musician playing golden oldies into an interpreter of contemporary songs with vision, re-honing his craft. Mentally, he returned from living in the past to living in the present and creating new interpretations, which revived a sense of direction to his life. He connected to younger generations and inspired them with his interpretations as he mutually was inspired by their music.

Not only in the mental and spiritual domains did he regain strength, but also in the physical domain. Rubin engaged a befriended physiotherapist. Physical exercises got Cash out of his wheelchair and walking independently again, while simultaneously bringing back feeling in his fingers to play the guitar with agility. By exercising his body, energy returned and he was able to sustain longer recording sessions, his most valued passion.

Rubin is an artist, not a doctor. He did not cure Cash. Instead he gave a man whose health was rapidly declining renewed opportunities and stimuli to thrive and find meaning in his life. Cash often said that all he wanted was to make music. The music gave him the will to survive, and to fight the diseases.

Although the medical records of Cash are confidential, reports from his family share indications that he was overmedicated. According to his son, his father would have lived longer and produced more songs and recordings if the medication had been decreased – something his physiotherapist pleaded for several times after another hospital admission.

Returning home after this hospital stay, every inch of his body appeared unduly medicated. As well meaning of his professional caregivers were in prescribing such pill-induced treatments, he actually lived in a medical cage, and his brilliant mind suffered. Fortunately some of his family members and friends understood he needed physical, mental, and spiritual space to flourish. They helped in opening that cage with recovered mental and physical strength and he eloquently delivered to us some of the most heart-provoking songs in the history of music.

Cretien van Campen is a Dutch author, scientific researcher and lecturer in social science and fine arts. He is the founder of Synesthetics Netherlands and is affiliated with the Netherlands Institute for Social Research and Windesheim University of Applied Sciences. He is best known for his work on synesthesia in art, including historical reviews of how artists have used synesthetic perceptions to produce art, and studies of perceived quality of life, in particular of how older people with health problems perceive their living conditions in the context of health and social care services. He is the author of The Proust Effect: The Senses as Doorways to Lost Memories.

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Image credit: Johnny Cash 1969, Photograph by Joe Baldwin. Public Domain via Wikimedia Commons.

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Eugene H. Rubin, MD, PhD is Professor and Vice-Chair for Education in the Department of Psychiatry at Washington University in St. Louis – School of Medicine.  Charles F. Zorumski MD is the Samuel B. Guze Professor and Head of the Department of Psychiatry at Washington University in St. Louis – School of Medicine, where he is also Professor of Neurobiology.  In addition, he is Psychiatrist-in-Chief at Barnes-Jewish Hospital and Director of the Washington University McDonnell Center for Cellular and Molecular Neurobiology. Together they wrote, Demystifying Psychiatry: A Resource for Patients and Families, which offers a straightforward description of the specialty and the work of its practitioners.  In the excerpt below we learn about the prevalence of psychiatric disorders.  In the original article below they argue for funds to support drug prevention rather than for research for the resulting medical problems.

Heart disease, cancer, and stroke are the leading causes of death in the US. This is well known. What is less well known is that cigarette smoking (nicotine dependence) is the most important preventable contributor to these causes of death and alcohol abuse is the third most important contributor. These two legal substances have substantial addiction potential and together account for more than 400,000 deaths per year in the US. Once a young person smokes more than about 100 cigarettes, his or her chances of becoming addicted are substantial. Long term risky drinking predisposes a person to many health consequences in addition to enhancing the risk of becoming alcohol dependent. Risky alcohol use is defined as drinking 5 or more alcoholic beverages (12 oz beer equivalents) over a few hours on repeated occasions (actually, it is 5 drinks for men and 4 for women).

When misused, alcohol can lead to job loss, destruction of relationships, and a myriad of physical ailments not to mention its contribution to increased rates of traffic accidents, violence, and suicides. Alcohol-related disorders are major reasons why our emergency rooms (ERs) are so busy.

Cocaine, methamphetamine, and heroin are illegal drugs that with repeated use can take over a person’s ability to behave rationally. These addictive drugs have severe physical and psychiatric consequences. They destroy relationships as well and harm society in obvious ways. They also increase our health care costs and tie up our ERs.

All of these drugs, including nicotine and alcohol, hijack the brain’s motivational system and hamper its executive system (the part of the brain that helps us think, plan, and learn). Each drug interacts with the “wiring” of these brain systems in different, but related, ways. The cigarette smoker who reaches for a smoke before getting out of bed in the morning, the alcoholic who needs an eye-opener to start the day, and the woman who prostitutes herself in order to get her next injection of heroin – all are responding to the control of an abused substance.

Charles F. Zorumski, M.D. is the Samule B. Guze Professor and Head of the Department of Psychiatry at Washington University in St. Louis – School of Medicine, where he is also Professor of Neurobiology.  In addition, he is Psychiatrist-in-Chief at Barnes-Jewish Hospital and Director of the Washington University McDonnell Center for Cellular and Molecular Neurobiology.  Eugene H. Rubin, M.D., Ph.D., is Professor and Vice-Chair for Education in the Department of Psychiatry at Washington University in St. Louis – School of Medicine.  Together they wrote, Demystifying Psychiatry: A Resource for Patients and Families, which offers a straightforward description of the specialty and the work of its practitioners.  In the excerpt below we learn about the prevalence of psychiatric disorders.

Studies examining the frequency of psychiatric disorders in various populations are done by epidemiologists.  These are scientists who investigate patterns of illnesses, as well as their causes and prevention.  They play key roles in describing epidemics and in identifying factors associated with the spread of a disease in a population. Ideally, they would like to study an entire population, such as the entire US population or the entire population of New York City.  However, that is usually impossible (due to economic costs and logistical challenges associated with such a massive research undertaking), so epidemiological studies rely on obtaining representative “random samples of the people of interest. Based on these random samples, epidemiologists use statistics to estimate the frequency of an illness in a large population (called the “incidence” of the disorder).  Admittedly, this is a crude description of the science of epidemiology.  Nonetheless, for our discussion, these definitions will suffice.

How Common Are Psychiatric Disorders?

There have been several studies examining the frequency of psychiatric disorders in US populations.  Examples include the Midtown Manhattan Study, which was conducted in the 1950s, and the Epidemiological Catchment Area (ECA) Study, which was conducted in the 1980s.  More recent studies include the National Comorbidity Study (NCS), the National Comorbidity Study-Replication (NCS-R), and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), among others.  These large studies have provided important insights into the nature of psychiatric disorders in the United States…the data from the NCS and NCS-R obtained from 1990 to 1992 and 2001 to 2003, respectively, indicate that the prevalence of psychiatric disorders in the adult US population (ages 18-54 years) is estimated to be about 30% (i.e., about one in three persons has a diagnosable psychiatric disorder during those periods).  Based on other data, the prevalence may approach 50% when considered from a lifetime perspective (i.e., one-half of the US population is likely to have a psychiatric disorder at some point in their lives).  Those are staggering figures and are a strong indicator that almost every person in the United States has some contact, knowingly or not, with persons with mental illness. When we consider the complexity of the brain systems that may be involved in various psychiatric disorders, these figures make sense….our brain motivation and reward systems are critical for our survival. However, these systems can be easily hijacked by drugs of abuse; this likely contributes to the prevalence of the various substance abuse disorders.  Similarly, our brains’ emotional systems are critical for how we function and survive.  For example, some degree of anxiety can be healthy and can help motivate us to protect ourselves against an obvious threat.  But the systems governing anxiety and fear are highly regulation and can be turned on and off by a variety of stimuli, both appropriately and inappropriately.  It is not too much of a stretch of the imagination to see that perturbation or overuse of these systems can interfere with our everyday functions (e.g. too much anxiety can be crippling).  The same may be true for brain systems involved with mood or perceptions.

You’ll recall that some good news/bad news scenarios came out of NCS and NCS-R.  The good news indicated that the prevalence of mental illness in the US adult population did not increase over the 1990s and that treatment for mental disorders increased over that time from about 12% of the population to 20%.  The bad news was that, despite the increase in treatment, almost two out of three patients with a psychiatric diagnosis did not receive treatment.  Additionally, about half of the patients treated for a mental disorder actually did not have a diagnosable mental disorder, possibly reflecting the tendency of some physicians to treat symptoms and not disorders.  For example, a person may report feeling sad to a primary care doctor, and then be prescribed an antidepressant.  However, another doctor, inquiring a little more deeply, may find that this person does not meet diagnostic criteria for a clinical depression and thus probably does not require pharmacologic treatment.  As noted earlier, sadness does not equal depression.  Sadness without other symptoms suggestive of depression may be a healthy and realistic response to a situation.  With a little bit of support and time, the sadness is likely to resolve.

The results from the NCS-R are consistent with other studies.  For example, a recent survey by the World Health Organization (WHO) indicated that about 25% of the US population has a psychiatric disorder, but that only about 15% of these people actually get treatment.  The perverse “good news” in the WHO study is that those who were defined as “seriously ill” had about a one in two chance of getting treatment.  That is, if you are really sick, you have a higher likelihood of getting treatment than if you are more mildly ill; unfortunately, a 50% chance of getting treatment means that a lot of seriously ill individuals are not getting the care they need.  Taken together, these are sobering data and indicate that psychiatric disorders are very common but poorly understood and very poorly treated in the US health care delivery system.

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Tim