develop reactive depression. If the illness is longlasting, poorly
understood, or disabling; if the patient has a sense of injustice,
invalidation, or abandonment; or if the diagnosis is contested or
litigated, the depression may be aggravated. The care of these
patients must include attention to mental health issues.

Third, environmental and occupational physicians confront a
variety of poorly defined and in some cases overlapping syndromes,
including multiple chemical sensitivity, closed building syndrome,
Gulf War syndrome, and chronic fatigue syndrome. Patients present
with diffuse symptoms, often including constitutional and psychi-
atric symptoms, that they associate with environmental exposures.
Often they are firmly convinced of the environmental origin of their
ailment by the time they visit the physician. In at least some cases,
there is psychiatric co-morbidity. In most cases psychiatric evalu-
ation is helpful.

Fourth, a deeply rooted link with nature may lie at our core, a part
of who we are as a species, contributing to our spirituality and our
sense of wholeness. E. O. Wilson called this affinity biophilia, and
in recent years ecopsychology has proposed a therapeutic paradigm
based on it. As clinicians, we may find this a useful perspective,
recognizing the value of such "therapies" as time outdoors or with a
pet. As advocates, we may also find this a useful perspective, recog-
nizing that the public health importance of environmental protection
extends to mental health.

Finally, in a field that sometimes offers more questions than answers,
that lacks some of the easy certainties of surgery or pediatrics, and in
which some of our patients are needy, demanding, and difficult, there
is another lesson we can learn from our psychiatric colleagues. We need
to take a close look at our own behavior. The defensive reactions of
some physicians to patients with multiple chemical sensitivity go
beyond scientific skepticism, suggesting that our own backgrounds and
emotions color our therapeutic perspective.

For all these reasons, environmental and occupational health
professionals need to collaborate with mental health professionals.
Dr Lundberg is to be congratulated for assembling this splendid
collection of essays on the environment and mental health. I hope it
will be widely read by professionals in both fields, stimulating greater
awareness of the areas of overlap and fruitful interdisciplinary ex-
changes. Ultimately, this can only advance the goals that are impor-
tant to us all: better care of individual patients, and more effective
advocacy for a clean, healthy environment.

-x-