Book Review

The Environment and Mental Health: A guide for clinicians

N Engl J Med 1999; 340:1051April 1, 1999

Article

The Environment and Mental Health: A guide for clinicians
Edited by Ante Lundberg. 233 pp. Mahwah, N.J., Lawrence Erlbaum, 1998. $59.95. ISBN: 0-8058-2907-5

“The elements are simple bodies. They are the primary components of the human being throughout all its parts, as well as of other bodies in their varied and diverse forms. The various orders of beings depend for their existence on the intermixture of the elements.” Thus wrote the Arabian philosopher Avicenna, author of The Canon, a textbook of medicine widely used in the Middle Ages throughout Europe and the Middle East. The elements were fire and air, earth and water.

Modern science has a different concept of the elements but perhaps not of the philosophical abstraction by which all bodies in nature depend for their existence on the intermixture of the basic elements. In fact, Avicenna's dictum could very well be adopted today as the motto of the new medical science of environmental and occupational medicine. Human interaction has stirred the environment, and the cloud of invisible dust thus created blocks the heat and grows incessantly. The particles fill our nostrils, seep through our skin, contaminate our water, merge with our food, and enter our system through all pores and orifices, eventually to be incorporated as spurious chemical elements of our bodies.

The physical and mental consequences of such widespread pollution could be subtle, insidious, and difficult to identify; it is a process that generates anxiety and depression, if not paranoid ideation. Scholars may ponder whether human reactions to the invisible cloud constitute a mental response to the unknown or a direct consequence of physiologic mechanisms deranged by the particles of the poisonous dust.

Modern medicine has responded to the challenge by creating the discipline of environmental and occupational medicine. Its charge is to identify, analyze, quantify, and remedy the pathologic consequences of a disturbed ambience. The evidence of something gone amiss is overwhelming in some instances, suggestive in others, and only speculative in most. The release of radioactive material in the air after the fire at the Chernobyl nuclear plant in 1986 exposed millions of people to excessive amounts of radioactive fallout. An estimated 60,000 cases of cancer are directly linked to the disaster. Troublesome somatic and psychological symptoms in veterans of the Persian Gulf War have been attributed to chemical and biologic warfare, mycoplasma infection, oil-well fires, and exposure to depleted uranium, but definitive proof is still lacking. The quality of indoor air in urban settings may be compromised by pollutants, irritants, and contaminants, a concept that appeals to office workers who do not feel well. Although many physicians remain skeptical of the existence of a sick building syndrome, a growing number of workers report feeling the effects of the degraded indoor environment. Speculation is rampant, but a definitive study with objective end points has not been conducted.

The Environment and Mental Health is a courageous attempt by a selected group of experienced professionals to describe and explain the behavior of the characters involved, physicians and patients alike, in the intersection between environmental and occupational medicine and mental health. Changes in climate and radiation are in part the result of human activity and have revealed the fact that nature is less eternal and more vulnerable than we used to surmise. Then, there is the direct toxicity caused by chemicals and physical agents, some, like mercury, known since antiquity and others of recent acquisition. The short list of chemical agents that cause environmental illness includes pesticides, nitrates, volatile organic compounds, lead, arsenic, cadmium, copper, heavy metals, polychlorinated biphenyls, and radionuclides such as strontium-90 and cesium-137.

Changes in mood, cognition, and behavior heralding a toxic encephalopathy mingle with stress and reactive depression aggravated by skeptical attitudes, a sense of injustice, and failed litigation. In many instances lack of definition, diffuse manifestations, and overlapping psychiatric and constitutional symptoms such as those in the Persian Gulf War syndrome, cloud much of this medical territory. Cognitive, behavioral, and biologically oriented treatments have been amply covered in book-length reports, yet the problem continues, attesting to the fact that its complexity is as deep as human nature.

Many factors influence perceptions of environmental risk and the coping strategies selected. Patients with environmental illness are generally dissatisfied with traditional medicine and physicians' attitudes. The Environment and Mental Health addresses the problem and offers insights that are worth retaining for future reference. The end of the book contains an instructive discussion of biophilia, the “innate tendency to focus on life and life-like processes,” and biophobia, a coherent fear of nature involving, for instance, animals (e.g., lions), arachnids (e.g., spiders), and natural situations (e.g., thunderstorms).

The book judiciously points out the lack of reliable clinical end points for a study of environmental illness, the need for better objective measures of health outcomes, and the risks entailed by relying on subjective ratings based on manifestations in persons under psychosocial stress. Despite the complexity of the subject and the inherent difficulty in centering on elusive targets, the book is well written and balanced in spite of having multiple authors. It ends with a helpful appendix listing hot lines, Internet addresses, sites on the World Wide Web, and federal agencies concerned with informing the public and professionals about health and the environment.

Antonio Culebras, M.D.
State University of New York Health Science Center, Syracuse, NY 13210