What I Learned: Part 1

Hello from San Diego and the 44th annual American Academy of Psychiatry and the Law conference. One of the annual traditions associated with this conference is my series of "What I Learned" posts, which preserves little factoids, pieces of trivia and topics for me for future reference, and also tells members a bit about what they missed if they couldn't make the conference. For those interested in a more real-time experience, you can follow live coverage on my Twitter feed @ClinkShrink.

In spite of a three hour time difference and associated jet lag I did make it to the morning poster session. While I didn't get to every single poster, I did enjoy one that looked at the rates of military service for prisoners who committed suicide in New York over several years. One of the interesting things about this study was the fact that it was exempt from IRB review because all of the information was in the public domain as the result of a journalist's FOIA request. Having completed the story, the journalist turned over all the data to the poster's authors. Sweet. I don't recall all the numbers due to jet lag and mawazo mengi (keep reading), but the bottom line was that only three percent of the prisoners who completed suicide had a history of military service. Weird. Are veterans less likely to kill themselves in prison than while on active duty?? The poster wasn't designed to answer that question, but it certainly did raise the question in my mind.

Immigration issues are an emerging area of active forensic work now, and this was reflected again in this year's conference. I attended a panel presentation by psychiatrists from Yale and the Philadelphia program, who talked about the basis for deportation ("removal proceedings") and the common questions asked of forensic psychiatrists. An alien can file to be protected from removal based on a real history of persecution or being members of a group at risk for persecution, by being a victim of torture, or if their life or freedom could be threatened by return to the home country. The respondent's testimony about these issues must be credible. Psychiatrists are sometimes asked to testify as to why an alleged torture victim may have inaccurate recall of details related to their experiences, or why their demeanor or emotional reaction while discussing torture appears to be inconsistent with the experience. (All of this discussion brought to mind the prosecution of rape cases where the victim is "put on trial.") A psychiatrist might be asked to testify about a respondent's diagnosis and treatment needs and whether those treatment needs can be met in the home country. One panelist talked about transference and counter-transference issues in immigration evaluations, particularly about her own discomfort about testifying about deficits in her own country of origin's mental health system. I also learned it's good to know about culture-bound syndromes for these evaluations, like "mawazo mengi" ("brain fag"---yes, that's "fag" not "fog") or racing thoughts with headaches.

I was quite pleased to attend a panel presentation about the Goldwater Rule. As regular readers know, this is a persistent interest of mine that I've blogged, podcasted and written about before (here, here, here, here, and here). Now, the Shrink Rappers are finally not the only ones talking about this. The AAPL ethics and peer review committee put on a joint presentation in which they played several television interviews with psychiatrists commenting on criminal defendants in the news as well as on the President. There was vigorous and unanimous agreement about where the talking heads "crossed the line" of professional ethics, how the interviews could have been handled better and what recourse our profession had to address the offenders. Complaints have been filed within the APA against media consultants who violated our ethical rules, and in some states this may also be the basis for a licensing board complaint. Interestingly, social media was not even mentioned. I suspected this may be due to an inherent fear and suspiciousness about the use of social media by forensic psychiatrists. On a side note, but one I plan to track, is that the role of psychiatrists in national security issues and consultation to covert agencies was presented as a "grey area" of ethics. (Oh, I'd say it was a darker shade of grey myself.)

Finally, I attended a panel presentation on the management and reduction of inpatient violence put on by some of my Maryland colleagues. There was a review of the literature on risk factors related to inpatient violence (staffing levels, patients with a history of substance abuse and/or violence, an overstimulating---noisy---environment) and also a presentation of one inpatient unit's plan to reduce inpatient violence. The unit set up a designated "milieu manager" who did hourly rounds on the unit to touch bases with all the patients and keep an ear out for emerging tensions. They did patient-specific limited and targeted observation (a change from the usual practice of continuous, 24/7 observation). I forget the numbers on the assault rate, but what stood out in my mind was that the scores on the patient satisfaction survey I think tripled. The unit got the hospital award for the most improved patient satisfaction. Very cool project, and it was all set up, designed and run by the nursing staff.

Finally, the evening entertainment was a showing of the 1938 film "The Amazing Dr. Clitterhouse." Definitely worth watching even if you only watch the insanity trial at the end of the film. I may need to track down a clip of the "expert" testimony in that case. For peer review, of course.

The conference runs through Sunday and you can follow my coverage today and tomorrow @ClinkShrink. Thanks for attending with me.

Your Patient Died. Who Cares?

 

 

I thought I'd share what I saw on my Twitter feed as soon as I got up this morning. I immediately felt a blog post coming on, particularly after reading the Twitter comments as they rolled in. I felt a bit sick, knowing what some of my colleagues in Ohio must be going through right now. This post is for you.

When it comes to patient suicide, correctional psychiatry is probably one of the higher risk subspecialties within psychiatry. The average prisoner has three risk factors for suicide before he even steps into the facility: he's male, young, and has an active substance abuse problem. There's even a recent study to suggest that being charged with a crime increases one's risk of suicide, even if that person is never incarcerated.

Considering this, if you practice correctional health care for a few years it's pretty likely that at some point you will experience a patient suicide, either as a health care first responder, as an administrator or as a mental health clinician. I feel like I need to write this blog post to warn you about something:

Don't expect your friends, family and colleagues to understand why you're upset that somebody died.

I know that sounds counterintuitive, but that's just the reality of correctional health care. The general public---and even some physicians---are going to instinctively give you a "who cares? He's just a criminal" response even if they don't know the person or what he was locked up for.

Let's consider the responses I've seen just today regarding the suicide of Ariel Castro, the man who kidnapped three women and held them prisoner for several years (comments drawn from a network news site):

• Great news! Seriously, it's great that Ohio taxpayers won't have to pay to house and feed this scum bucket.
• He did society and himself a favor....good thing he's gone!
• Too bad that he didn't live to be locked up and suffer for a few decades.
• Too bad he couldn't have been chained to a wall while the inmates he was being protected from got rewarded for taking turns demonstrating the receiving end of his version of the universe. Can't exactly hang yourself when your chained to a wall. Cruel and unusual? If it's not cruel and unusual, it's not punishment.

Yeah, that could be your patient they're talking about. And all your patients watching the news or reading a newspaper will see this public reaction and know that the rest of the world truly could care less about them. Your job, temporarily, is about to become much harder. Fingers will be pointed, armchair psychologists who have never set foot in your facility will "know" how the system or you as a clinician must have failed, and new redundant policies will be created that will make your health care delivery system less efficient.

This will pass. Eventually, people will grasp the fact that this man who successfully hid multiple felonies for several decades probably also had the skill to hide a planned suicide attempt. Your colleagues in other parts of the country will step up to the plate to remind the media, and the general public, that correctional and forensic psychiatrists are taking an active role to implement suicide prevention policies and training that have dropped the correctional suicide rate substantially in the last twenty years.

And maybe, just maybe, it will lead people to recognize the importance of what you do.

Just a few thoughts from inside the walls, given that next week is National Suicide Prevention Week.

Why Are Inmates Dying?

In yesterday's New York Times there was a story by Erin Banco called Suicides Worry Experts at Big Jail in Capital. The story talks about four deaths at the DC jail this year and the general worrying trend of increasing correctional suicides nationally. The article speculates that the deaths may be attributed to lack of adequate mental health staffing or deficiencies in the jails' observation practices. Some of the people interviewed for the story linked the deaths to cutbacks in state mental health budgets.

Correctional suicide is an area that, as Dinah would put it, is a "Clink" thing---a topic I've been interested in for a number of years. I wrote about this three years ago in an article called Correctional Suicide: Has Progress Ended? In my article I pointed out that nationally we seemed to have hit a "floor" with regard to suicide prevention---rates had been declining consistently over the years until a recent plateau. I wrote about what I thought might be the cause of that plateau: the Prison Litigation Reform Act which limited prisoner access to the courts and circumscribed how far courts could intervene to improve prison and jail conditions,  as well as changes in the profile of the typical correctional suicide, and the increasing problem of gang violence and intimidation in corrections.

What was most striking for me then was the fact that correctional suicide studies are starting to show increasing numbers of inmates who die from suicide without any previous mental health history or history of suicide attempts. I coined the term for this phenomenon a "clean" suicide---one that could not have been picked up or prevented through currently accepted screening methods and referral protocols. The New York Times article didn't address this, but I couldn't help wondering if the deaths in the DC jail might fall into this category.

What I didn't mention in my earlier paper---because the numbers weren't out yet---was that the increase in jail and prison deaths may reflect a larger trend in rising national suicides. According to the CDC, the age-adjusted death rate for suicide has increased by 8.7 percent since 2000. The other new data comes from the recent Department of Justice report on inmate sexual victimization and abuse. According to this national survey, being a sex offender increases the by other inmates. The Washington Post has reported that three of the four DC jail deaths were by detainees who were charged with sex offenses.

The Times may be correct that cutbacks in state mental health budgets have had an effect, but this does not address the fact that for many states the funding for correctional health care comes out of the public safety budget rather than the health and mental hygiene budget. State cutbacks could still play a role, just not through the route the article suggests. States with privitized correctional health budgets would also have to be examined separately to look for contractual budget changes.

So those are my thoughts about the NYT correctional suicide story. I figured I'd better get this post up fast before Dinah nudges me to write about it. (Yeah I know, I'm supposed to be re-reading the book proposal but Dinah you know I had to blog about this.)

Dinah is Mad

A few days ago, I posted a link to what I thought was a nice article in the New York Times about a special team of NYC police officers who talk people out of jumping off bridges and buildings, and even jump into the waters to fish them out.  The responses to the post and to my comments left me a bit distraught.  It's been a while since Shrink Rap has been this contentious, and it left me feeling rather defensive.  I tried to put up a response in the comment section, but my comment was too long, so I'm posting it as it's own post.

First, Sarebear, thank you.  She wrote:

"The range of human behavior, motivations, reactions to illnesses is huge. Just because it's not YOUR experience, doesn't mean it isn't valid as someone else's. Just because your experience isn't THEIR experience, doesn't make yours invalid either."

Brilliant.  Thank you.

To the assortment of anons who felt inspired to write in with:

"Yet again, I wonder if this is how you interact with your patients. How do you maintain a practice? Or do you perhaps see only the very mildly mentally ill, the slightly neurotic."  and " It's also surprising that both of you claim enough knowledge of suicide to present at a conference."

I think you should find other another psychiatry blog.  This is far beyond the realm of what one would say to someone in their living room, and the readiness with which you insult us is as though we are not human beings with feelings!  I showed this to my husband whose response was "I don't know why you do this and why you would interact with people this way." 

My comment on the damage suicide leaves in it's wake is a statement of fact.  One friend told me that she started to feel just a little better five years after her son's suicide.
A reader responded that my comment was "demeaning and insulting." " Of course every suicidal person has considered carefully, long and hard, the effect his or her suicide will have on his loved ones. The implication that they have never thought such a thing is really offensive." 
To the anon who wrote:
"Dinah, it sounds like you've never treated suicidal people. If true, it is surprising."
I have never treated a patient who has successfully committed suicide.  I have treated two patients who have had serious attempts while under my care, and many who have had serious attempt before they were my patient.  In general, a serious suicide attempt is reason change doctors -- it is a sign that the treatment is not working, and it destroys trust.

And while I have not treated many seriously suicidal patients, most people with depression have suicidal thoughts and feelings, different from what it takes to complete the actual act. On the rare days when the thoughts seem like anything more than thoughts, I have no qualms about telling my distressed patient that I would be devastated if they committed suicide.   

I can't count the number of people I have treated who have had relatives commit suicide, but it's a lot.  Should we start with the woman whose husband waited until she was coming up the walk to shoot himself in front of her? That began her long and involved time as a psychiatric patient.

No, it's not always thought out enough to be "selfish," (I never used that word) sometimes it's from psychosis, sometimes it's a teenager who can think of no other way to deal with heartbreak, sometimes it's an escape, other times it is the by-product of overwhelming depression.  It's still leaves generations of pain.

  Over 38,354 died by suicide in 2010, despite the best efforts of psychiatry, the NYPD jumper team, and the lack of mental health euthanasia teams.  That number doesn't count the suicides done in ways that medical examiner might have deemed accidental.

Jane, we don't believe that people with intractable psychiatric problems should kill themselves, much less have an institution promoting euthanasia for the mentally ill (what's next?).  We believe they should change doctors, try different or unconventional therapies, seek other opinions from experts,  and we see psychiatric conditions as treatable.

Re: The suicide prevention conference: they invited us to present, we had never heard about the conference before.

I am sorry to be so defensive.  The comments from this post left me very angry. 

I will leave you with a quote from the comment section of the NYTimes article on their Special Teams:

  Casey from Denver wrote:
This work is profoundly important because many people thinking of suicide change their mind. A study by Dr. Richard Seiden of people prevented from jumping from the Golden Gate Bridge found that after an average of 26 years, 94% were still alive or died of natural causes. One of the rare jumpers who survived said later:
“The last thing I saw leave the bridge was my hands. It was at that time that I realized what a stupid thing I was doing . . . It was incredible how quickly I had decided that I wanted to live.” So keep up the good work, you brave men and women of the Emergency Service Unit!

Reading While Depressed

I have to get off that suicide topic. Here's something a little more helpful:

In the current issue of the Paris Review, a reader writes in asking what she should read while depressed. Review writer Sadie Stein answers with a number of interesting suggestions, followed by 67 reader comments with additional ideas.

If you need to clean your head out from our last post and discussion, read this:

Life-Affirming Reads

Murder of the Self

Darn you, Blogger. I'm trying to get two presentations done along with lots of other work and there you go, distracting me.

So we have the issue of suicide and criminal law and a discussion of whether it's a crime to kill yourself. Dinah and I just did a presentation about social media and suicide at a local conference on suicide, so the topic is fresh in my mind.

To my knowledge there are no states that still have laws against someone who attempts suicide. In some states, suicide is a common-law crime that could bar recovery in civil cases (and insurance companies don't pay out for the survivors of people who kill themselves).

The complications come up when the suicide attempt puts others at risk. When someone shoots himself and lives, but puts others in danger during the act he could be charged with reckless endangerment or criminal negligence (as well as the associated handgun offenses if applicable). Yes, people have gone to prison for this. Possession of a controlled substance without a prescription, even if possessed for the purpose of suicide, is a crime.

A lay person who forms a suicide pact with someone could be guilty of conspiracy to commit murder (at worst) or aiding and abetting a suicide. Euthanasia, the killing of a terminally ill person, is less of an issue now that we have living wills and advance directives. There is no constitutional right to assisted suicide, by a physician or anyone else, according to two cases decided in the 1990's by the U.S. Supreme Court. Few states allowed physician-assisted suicide, and many have recently passed laws banning it.

Suicide is similar to drug addiction in that both could be considered "status offenses"---it's not a crime to be who you are (someone with suicidal ideation or someone with an addition to drugs), but it could be a crime to possess the materials to express who you are (drugs, a gun, etc) or to carry out some aspects of the behavior (buying the drugs, firing the weapon, etc).

No time to put up specifics about which states and how many of them do what, just an outline of the issues FWIW.

Capitated care, Young Brains, & Suicide Prevention Police

Thank you to everyone has been participating in our multi-post discussions of Capitated Care versus Fee-for-Service.  Based on the input of our readers,  I've come to the conclusion that in systems with capitated care (i.e., a national health system): 1) Our readers are pleased with that, feel it provides better blanket coverage to a large population and the emphasis is more on medicine and less on money.  2) Capitated care is less about service with a smile.  3) Capitated care does a better job with treating populations but may not be the best care for the individual with an outlier problem.  We've heard about systems in Canada, the UK, and Hong Kong, and of course, the USA.  I can't recall whether our Australian readers chimed in.

In today's New York Times, I wanted to give a shout out to a couple of articles about psychiatry. 

Robert Cantu and Mark Hyman have a book out called Concussions and Our Kids, and Dr. Cantu has an op-ed piece in today's paper, "Preventing Sports Concussions Among Children,"  talking about measures we should take to prevent brain injury during routine team sports for children under age 14.  The bottom line: children should not play tackle football, head the ball during soccer, body-check in hockey,  add chin-straps to batting helmets and eliminate head-first slides in baseball, and require helmets for field hockey and lacrosse players.  As psychiatrists, we're rather fond of intact brains.  The authors challenge us to re-think our approach to children's sports.  

The New York Times also has a nice article on the NYPD's Emergency Service Unit, an elite squad of 300 police heroes who talk people off bridges and rooftops.   So far this year, the NYPD has gotten 519 calls for people who are about to jump.   See Wendy Ruderman's, "The Jumper Squad."

Suicide and You

Clink and I are talking at at Maryland's 24th Annual Suicide Prevention Conference next week.  When we were asked, we told them that suicide was not an area of specialty for either of us, and that we usually speak about the Public Face of Psychiatry and ways that blogs, podcasts, twitter, Facebook, and good old fashion books like Shrink Rap can help people understand what it is that psychiatry is all about.  They told us that was fine.  Still, we'd like our workshop to be relevant to the overall topic at hand, so I thought I would ask you to share your experiences with us.  

If you've been suicidal, what helped get you through? 
Did a mental health care professional say or do anything that was helpful?
Did hospitalization help?  Did medicine help?
If you had a serious attempt, do you think there was anything someone could have said or done to have prevented your attempt?  
What keeps you from acting on suicidal impulses?  What has pushed you towards acting on them?

As always, thank you for your help.  We continue to learn a lot from our readers!

Is it Different for Guys?

Men are less likely to get treatment for psychiatric disorders, more than half of those who seek help are women.
Men are less likely to attempt suicide. 
But men have three times the number of completed suicides than women: they choose more lethal methods.


Are men different?  


Here's the beginning of the Mission Statement from a site called Mantherapy.org:


Working aged men (25-54 years old) account for the largest number of suicide deaths in Colorado. These men are also the least likely to receive any kind of support. They don’t talk about it with their friends. They don’t share with their family. And they sure as heck don’t seek professional treatment. They are the victims of problematic thinking that says mental health disorders are unmanly signs of weakness. And I, Dr. Rich Mahogany, am dedicated to changing that.

Part of a multi-agency effort, including the Colorado Office of Suicide Prevention, Carson J Spencer Foundation and Cactus, Man Therapy™ is giving men a resource they desperately need. A resource to help them with any problem that life sends their way, something to set them straight on the realities of suicide and mental health, and in the end, a tool to help put a stop to the suicide deaths of so many of our men.


So went to ManTherapy and listened to Dr. Rich Mahogany (I think he's an actor, the site says he's not a real therapist), I surfed around his office where there's  a dead creature with antlers on the wall, seating that's from a baseball stadium, and I took part of his symptom checklist test (it's not the M3).


The site feels like a parody of all things masculine.  I'm not a man -- so I'm not sure how to call this -- but I think if I were a distressed man, this wouldn't make me feel more comfortable getting help.  It's not that listing resources might not be useful, but I just wasn't sure.  If you feel like checking it out, surf over to Mantherapy and tell me what you think. 

Mental Health, Military Style-- Guest Blogger Dr. Jesse Hellman

Today, we're talking about mental health and the military.  But first, I just learned, via Facebook, that today is International Polar Bear Day.  If you have one, hug him tight.  Make sure he's been fed first.


Over on his own blog, Pete Earley, has a post up about a veteran who was about to kill himself with a homemade gun.  He called a Suicide Hotline, the police were sent and the patient was charged with possessing a homemade gun.  It's a good post, worth the read, and Earley brings up issues about mental health emergencies and the legal system that aren't limited to veterans. 


Yesterday, the New York Times had an article about military discharges for a diagnosis of "personality disorder."  The diagnosis is presumed to be a pre-existing one, so once a soldier is diagnosed with a personality disorder, he can be discharged without the usual military benefits.  I know that our guest blogger Dr. Jesse Hellman  has an interest in the topic.  He spent two years as a military psychiatrist, and has attended hearings on the topic, so I asked him to do a quick guest post for us:


Jesse writes:
  The article tells of a 50 year old woman psychologist who enlisted, was sent to Afghanistan, and was involved in a number of incidents, eventually being accused of sexual harassment for remarks she had made. She was sent for psychiatric evaluation and was given the diagnosis of personality order on discharge. There are severe consequences of this diagnosis, which can include loss of future benefits, medical expenses, and more. Was the diagnosis properly considered? Did her commanding officer ask that she be given that diagnosis in order to reduce the huge medical expenses produced by the military?

This is not the first time I had heard of this problem. In the fall, I attended in Washington a meeting of the House Committee for Veteran Affairs. Joshua Kors, a writer who had several pieces in The Nation which addressed this very problem, was testifying along with a soldier who had been discharged as having a personality disorder. The Department of Defense sent several people to testify that there was no abuse of the diagnosis.

One of Mr. Kors's strongest points was the sheer number of personality disorder diagnoses that were being made. It looked like these were occurring at two bases in the United States that processed discharged soldiers: Could it possibly be that this number of applicants slipped through the initial screening process?

My own impressions were mixed. It seemed inconceivable to me that any military commander would directly order physicians to misdiagnose in order to reduce costs to another entity. Vastly too great a risk to him, and to what advantage? On the other hand, the diagnosis as described in the DSM is more severe than the problem warrants: it is possible that many soldiers enlisted thinking the military was for them but then, through various routes, found that life in Afghanistan, under fire, with all the dangers and rigors, was too much. Their attitudes disintegrated. They wanted out. They were poor soldiers who disrupted morale.

To those who understand how to use bureaucracy to effect one's ends, direct orders are not needed. If it takes one hour to examine a soldier and find a given diagnosis, but alternate diagnoses require much more paperwork, repeat examinations, record reviews, etc, and the caseload of the examiner is sufficiently great, is it not predictable that the particular diagnosis that minimizes work will increase in comparison to the alternatives?

So what do you think? There are many issues here worthy of discussion.

This Week In The News

There are a lot of stories in the news lately that have a forensic connection: the disgruntled noncustodial father who blew up his house (and kids), Madonna's stalker who eloped from a psychiatric hospital, a recent legal decision out of Georgia about assisted suicide, and an inmate with gender identity disorder who may be the first to get a state-sponsored sex change operation.


Where to begin, where to begin?


The Georgia decision has personal relevance since it means one of our retired local doctors won't face murder charges for offering advice and encouragement from a distance to someone who died of suicide there. The Georgia Supreme Court decided that the law banning suicide in that state was unconstitutional since it barred mere conversation about the issue separate from any act of aiding a suicide. As such, it was an unlawful infringement on free speech. It's hard to believe that it's been five years already since the first time I've blogged about this topic and fifteen years since the US Supreme Court said it was OK to ban it. Over half the country has laws against it now, but I don't know how many, if any, could be at risk because of the issue with the Georgia statute.


The story about the inmate with gender identity disorder (found thanks to my friend Lorry Schoenly's twitter feed---thanks Lorry! please follow her) also interests me because it's an emerging issue in the treatment rights of prisoners. Specifically, prisoners with gender identity disorder. We've talked about gender identity disorder before on podcasts number 20 and 21 (which included an interview with Dr. Chris Kraft about evaluation and treatment), respectively. I blogged about the history of right to treatment for prisoners here, but there's been one significant change since that 2006 blog post: courts have decided that gender identity disorder does constitute a serious mental disorder which requires treatment. What the courts are arguing about now is whether that right to treatment includes sex change operations. The state of Wisconsin passed a law to ban use of health care funds for this, but that law was overturned as unconstitutional. Prisons are required to continue hormone therapy if it was being prescribed prior to incarceration, though.


Separate from the issue of treatment, GID prisoners don't have a right to dress in opposite sex clothing or to have access to makeup. They don't have a right to be housed in a facility consistent with their gender identity. (Female prisoners sued, and won, cases alleging invasion of privacy when male-to-female GID inmates were housed in a female correctional facility.)


So that's where we are on the GID inmate front. Regarding the Madonna stalker, well, I have some personal experiences with psychotic stalkers but since I don't blog about specific patients that story will go untold.


That leaves the child murder story. Ugh. No thanks. I've seen these cases, they're awful, I'd rather not dwell on them. I'm taking a personal pass.

Can Facebook Prevent Suicides?

Facebook is launching a new suicide prevention chat hotline for those who post worrisome comments on their walls.   From an article in Newsday:

Here's how it works:

A user spots a suicidal comment on a friend's page. He then clicks on a "report" button next to the posting that leads to a series of questions about the nature of the post, including whether it is violent, harassing, hate speech or harmful behavior.
If harmful behavior is clicked, then self-harm, Facebook's user safety team reviews it and sends it to Lifeline. Once the comment is determined to be legitimate, Facebook sends an email to the user who originally posted the thoughts perceived as suicidal. The email includes Lifeline's phone number and a link to start a confidential chat session.

The recipient decides whether to respond.
Facebook also sends an email to the person who reported the content to let the person know that the site responded. If a suicide or other threats appear imminent, Facebook encourages friends to call law enforcement.

Cheeseburgers for Yom Kippur...

Yom Kippur, the day of atonement,  is a solemn Jewish holiday.  It occurs at the beginning of the new year, and marks the end of a period of reflection.  While it the usual tradition to fast, Danielle Gelfand has a moving editorial in the New York Times where she talks about a tradition she has of eating cheeseburgers on the beach with her mother as they remember her father who died many years ago of suicide.    The author writes:

For the last 18 years, my mother and I have spent Yom Kippur, the holiest day of the Jewish calendar, at Tod’s Point beach in Old Greenwich, Conn., near where I grew up and where my mother still lives. I’m a TV producer living in Brooklyn now, but I still go back every year. My mom reads my father’s old prayer book while I order lunch for us from the greasy concession stand that stays open into the fall, double hamburgers with grilled onions and French fries.

To those who fast during the holiday, our version of a High Holy Happy Meal might seem sacrilegious, but we didn’t always spend it this way. We used to go to temple like everyone else. But when I was 17, my father, who had just turned 59 and had suffered from depression for many years, shot himself in the head. The police found his body two days later, on the eve of Yom Kippur. 

Do read the whole article at  Years of Atonement. 
 

Would You Like Prozac With Your Latte?

The Guardian recently published this story about a longitudinal Harvard study of 51,000 female coffee drinkers followed over ten years. They found that there was a 20% lower risk of clinical depression in the women who drank four or more cups of coffee a day compared to non-drinkers. This is consistent with a previous study of 86,000 female nurses followed over ten years, where they found that the relative risk of suicide was reduced even for moderate to low coffee drinkers, defined as drinking two or three cups per day.

This is good news for me since I usually start my day with a half a pot before I get to work. (Yes, that much, really. No wonder Dinah sent me a link to this story and said, "You've gotta blog about this.")

The trick is, there may be a ceiling effect to all this: once you get to eight or more cups a day this risk of suicide starts to increase again according to one study.

Somewhat gratuitously, the Guardian article threw in reference to our "druggy society" and faulted the researchers for not considering other factors like social supports, involvement in religious groups or community activities, and even whether the women were drinking coffee alone or with friends:

"As the scientists will also tell you, neurotransmitters respond to everything: hugs, kisses, conversation, books, pictures, gardening, hunger, worry, rows, war – all raise or lower chemical levels."

Ah yes, clinical depression and suicide must be the result of not getting enough hugs or the fact that you haven't taken up gardening. Cringe-worthy health reporting, at its best. The reporter concludes:

"...supposedly scientific comments of this sort serve little purpose except to coax women into a state the doctors can then medicate."

Amazing. A simple study about caffeine and depression has somehow been morphed into another nefarous plot by evil Dr. Pillshrink.

Podcast #60: On the Verge

Please take our sidebar poll and tell us who you are.
  If you don't know who you are, please guess.  

In Podcast Number 60, we discuss the following:

Questions from readers--

• Sarebear asks: What is a Nervous Breakdown?
• Mary and Max, an award-winning claymation movie about an 8-yo girl and a middle-aged man with Asperger's. Very educational about Asperger's, and extremely entertaining.
• Another reader asks: How are psychiatrists prepared to manage psychiatric disorders in patients with autism?

• The New York Time review of a movie, Beautiful Boy, which led us in to a discussion of guilt and blame and our desire as human beings to believe we have control over what happens to us.  Too bad none of us saw the movie.

• Clink talks about an article that appeared in the Archives of General Psychiatry, National Study of Suicide in All People with a Criminal Justice History.

• Finally, we talk (or perhaps "ramble" is a better word) about the psychology of podcasting.

Thank you for joining us!

****************************

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

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Committed!

There's all this 'stuff' I need to work on, but when it comes down to it,  I'd rather post on Shrink Rap then do any of the writing I need to get done for real work.  Why is that?

One of our readers has commented that she's been involuntarily hospitalized for 'suicidal ideation,' presumably in the absence on a plan or any intention.  Why is that?  We hospitalize people involuntarily when we believe they may be dangerous, but the truth is, many people who feel depressed have suicidal thoughts, this is not at all uncommon, 'dark thoughts' are frequently mentioned during treatment, and the truth is that if we hospitalized every patient who thinks about suicide, umm...there would be no where to put them and no one to pay for it.  Insurers put a huge amount of pressure on hospitals to keep people out and get people out.  I remember the ER patient who was suicidal with a plan to shoot himself.  The ER shrink called the insurance company to authorize the admission (it may have been voluntary) and the insurance company wanted to know if the gun was actually loaded! 

It got me thinking, how does a patient get involuntarily hospitalized for thoughts, with no intention to act on them?  I came up with a few ideas:

• The psychiatrist doesn't believe that the patient has no intention of acting on them.  Why would that be?  Somethings that might lead a psychiatrist to question a patient's word: A past history of a serious suicide attempt, especially a recent one.  A friend or relative in the docs face saying they are lying.  Another source of information that would indicate a lack of clarity about intent: a Facebook post saying "Goodbye, cruel world" a text message, something that makes the doc anxious.  Indications that there is a plan: the patient has been giving away valuable possessions, has written a note, has mail ordered a noose. 
• There is a mis-communication and the psychiatrist thinks the patient is having more active suicidal plans then the patient is actually having.  This might be sorted out if more time is spent evaluating the patient or discussing options with the patient, but there are all sorts of other issues which may be playing out unrelated to the patient: the psych ER has 8 people waiting to be seen and there are too many things happening for the psychiatrist/ER staff to give them each enough attention.
• There are other risk factors which leave the psychiatrist feeling worried: substance abuse, for example, a history of repeated ER visits, a history of violence.
• The patient has a severe mood disorder and there is concern that the patient won't follow up with out-patient care and the psychiatrist makes a paternalistic decision that it would be in the patient's best interest to get intensive, aggressive treatment in the hospital.  
• The psychiatrist has his or her reasons for being predisposed to being overly cautious:  a patient is thinking of shooting up a school with no intent, but there was a high profile case similar to that all over the news yesterday.
• The psychiatrist has his own baggage: a lawsuit for a suicide has left him feeling it's best to 'play it safe and admit for observation,'-- the patient looks like his mother who died of suicide, another patient who swore they had no intent then suicided outside the ER door.  All sorts of factors influence how a shrink thinks.
• A family member says, "He needs to be in the hospital, if you don't admit him and he kills himself, I'll sue your ass off."
• The patient refuses to commit to a safety plan.
• The psychiatrist is evil and loves power.  (I had to throw that in here)

This is our 1,500th post.  Thank you for helping me procrastinate.

Suicide, Free Will, and the Shrink's Magical Ability to Predict Violence

I'm posting over my fellow co-bloggers today.  So what else is new?

Please visit: Hot Grand Rounds-- The Summer Solstice medical blog posts with the pretty pictures, including a pink urinal with teeth.  One could ask for anything more?

And Please Visit Clink's post over on our Shrink Rap News blog on ethical issues related to the psychological report on the suspected Anthrax killer.   
When you're finished reading, please return Here to comment. 

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For a while now, we've been having discussions in our comment sections  about the issue of forced treatment: is it right or is it wrong?  Some readers are very clear: no matter how sick, no matter how imminently dangerous, no one should be held in a hospital ever against their will.  One reader tells us that suicide is a right of all persons as per their free will, and by the way, psychiatrists can't predict acts of violence and have no right pretending they can.  They should stand up to the legal system and say so, and not go along with the charade.

Both ideas got me wondering: is suicidal behavior that results in the attention of mental health professionals really a product of free will?  As psychiatrists, many of us believe that people have unconscious motivations--- they are guided by beliefs they are unaware they hold.  People commit suicide all the time-- In 2008, 34,598 people in the United States committed suicide, making it the 11th ranked cause of death.  Somehow they did it despite the proliferation of mental health professionals.  Many completed suicide with firearms, and my guess is that these deaths often occur without the immediate involvement of psychiatrists.  Those who wish to exert their free will to die often do so without alerting others or involving professional helpers.  It leads me to wonder if those that present to Emergency Rooms or to their outpatient psychiatrists might do so because they have an unconscious (or not-so unconscious) desire to be stopped.  Of course there are exceptions: those who are pulled off bridges, or discovered after a serious attempt that did not kill them.  Do we not summon medical care for an unconscious overdose victim on the theory that they may have wanted to die and we're interfering with the advancement of their free will?  

We put up a poll a few weeks ago where we asked if people would want to be treated by force if they had an episode of severe mental illness.  Of our 280 respondents, a majority, 57%, said yes while 42% said no.  Would the answers have been different if I'd asked a more provocative question: If you became psychotic and believed it necessary to kill your children, would you want to be treated?  It's too provocative a question for a poll, but I thought I'd throw it out there.  If you became demented, agitated, and combative towards those caring for you, would you want to be treated with a medication that increased your risk of death over the next year from 2% to 4%?

Don't worry, I won't be that provocative. 

The issue of predicting violence is an interesting one, and our reader is right that we're not terribly good at it.  Our most powerful magical tool is to ask the patient if they're planning to harm themselves or anyone else, and the truth is sometimes more legal than medical: we're told that if we don't ask and document, that if someone kills themselves, we'd lose a malpractice suit.  It does get boring asking perfectly well appearing people if they're thinking about suicide and homicide on each visit, but it is a required check box at the clinic.  If they say yes, we ask about a plan and intent, and it does seem it might be troublesome to the family if a hospital discharges a person who says they plan to leave to go shoot up a mall.  Or someone who has been actively psychotic, disorganized, and behaving in a dangerous manner.  There's medico-legal issues, but there is also common sense and kindness, and if you believe that someone who puts the barrier of the mental health field in the way of their violence may actually want help, even if they don't put it in those terms, then there is little to argue about.  Oh, go ahead, argue anyway.

Free will?  So many people who survive suicide attempts are glad they did.  So many who attempt do so for impulsive reasons that pass, or because they were intoxicated.  I'm not much for condoning a permanent solution to what are often temporary problems.

If you want to tell us that you were hospitalized for suicidal "ideation,"  this is another post for another day: I'm still thinking about that one. 

A Cry for Help

When Roy and I were on Talk of the Nation this past week, a called phoned in to ask about her sister. The question was about care in the Emergency Room/Department, so it was a perfect Roy question and he fielded it. I've been playing with it since, and wanted to talk more about this particular scenario, because the scenario was very common, and the question was more complicated than it seems.

From the transcript of the show:

ANN (Caller): Hi, thank you very much. I would like to ask Dr. Roy (oh, I gave him his blog name here) a question: My sister was admitted to emergency when she cut her wrists, and the doctor on call pulled me aside and said, do you think she was trying to kill herself?

And I said - because my sister is very intelligent - I said, if my sister really wanted to kill herself, she would have done it. I think she's asking for help.

And so he said - and so he had her see the psychiatrist who was on call, or on duty. And she spoke with him for a while. And he sent her home, saying: Well, if you need me, I'm here.

What I would like to ask Dr. Roy is, what protocol was going on there? Why did they allow that to happen? And what would you change, if you could?

----
Roy did a great job touching on issues of voluntary versus involuntary hospitalization and the importance of hooking someone who is looking for help in to outpatient care.

If this were more of a two-way conversation, I'd want to ask more questions. What did the caller think should have happened? Was the sister given a referral for outpatient care? Was she asked if she wanted one? Was she already in treatment? My sense --and I could easily be wrong-- was that the caller thought the patient should be admitted to the hospital. She was desperate and ready now for help. The doctor asked the sister if she thought the patient wanted to commit suicide; hopefully the patient was asked that as well.

So if the caller thought her sister should have been hospitalized, there are things about the 'system' she isn't aware of. Hospital inpatient units are a place that people go to be kept safe. In many ways, they are a holding place and the goals there do not include treatment back to wellness, but treatment back to safety. It's a very low bar, and it ends up that only those who are imminently dangerous, or so disorganized as to be at risk, get admitted from an ER. There are some exceptions: if the ER doc doesn't believe a patient who says he's not suicidal/homicidal, he may err on the side of safety and admit the patient, or if the patient's behavior seems unpredictable, he may get admitted. At a community hospital, a typical length of stay is only a few days, very little actual psychotherapy occurs in the hospital, and while medications may be started, people are generally discharged before those medications can take effect or even be brought to steady-state levels. Gone are the days of long-term hospitalizations. And because of the acuity of illness in those people who are admitted to the hospital, psychiatric inpatient units are often not very restful places. If you want peace and quiet, you're better off in a hotel where you can order room service, have a massage, sleep peacefully, and it costs a whole lot less.

Sometimes people are admitted to specialty units where more intensive treatment does take place which may take longer and may have a goal that goes beyond imminent safety. There are special mood disorder units, eating disorder services, pain units, trauma disorder services, or inpatient stays for ECT...but one doesn't typically get admitted to these from the Emergency Room and often issues of payment limit who can be admitted and for how long. Of course, there is Clink's favorite place, The Retreat, where you can get help in a very pleasant environment, and I imagine they would be happy to have the sister of the caller from the radio, but that is self-pay.

"Getting help" usually means going to an outpatient therapist/psychiatrist and it's not something that necessarily gets started while the moment is ripe. If there is a clinic associated with the hospital, they may have emergency slots for the ER to offer fast appointments, but other times, it can take many weeks to get a first appointment. Private practice varies a good deal-- I know shrinks who can get you in within the week, and others with a 6 week wait, and many who are simply too booked to take new patients.

I didn't write these rules, I'm just letting you know what they are. How do you think it should all work?

More Happiness, More Suicide?

On Tara Parker-Pope's NY Time Well Blog, she tells us that in places where people are the happiest, for example Denmark & Sweden, for example, have the highest happiness ranks, and the highest suicide rates. This is perplexing.

And apparently, the various United States are also ranked. New Jersey, where I grew up, is the 47th happiest state-- surprising given Full Serve gasoline, good pizza, and beaches. You were looking for something more out of life? Also it has the 47th suicide rate, so the miserable apparently tough it out.

Ms. Parker-Pope writes:

After analyzing the data, the researchers found a relationship between overall happiness and risk of suicide. In general, states with high levels of life satisfaction had higher suicide rates, according to the report, which has been accepted for publication in The Journal of Economic Behavior and Organization.
“Perhaps for those at the bottom end, in a way their situation may seem worse in relative terms, when compared with people who are close to them or their neighbors,’’ said Stephen Wu, associate professor of economics at Hamilton College. “For someone who is quite unhappy, the relative comparison may lead to more unhappiness and depression.”
Dr. Wu noted that other studies have found that people react differently to low income or unemployment depending on how common it is in their community. “If a lot more other people around them are unemployed, it doesn’t seem so devastating,’’ he said.

I'm not sure one idea leads to another. Could there be another factor here? How do suicide rates correlate with the availability of mental health professionals, for example? Or with the price of chocolate in a give region? And how happy is my state?

If you haven't taken our Shrink Rap survey on Attitudes Towards Psychiatry, Please do -- you can get to it by clicking HERE

Suicide, Brains, and Football

In yesterday's New York Times, Alan Schwarz wrote about the tragic suicide of football player Dave Duerson this past week. Schwarz notes that prior to shooting himself, Duerson texted family members that he wanted his brain examined for Chronic Traumatic Encephalopathy, a condition we've discussed before in our post Brains, Behavior, and Football.

Schwarz writes:

Doctors, N.F.L. officials and even many players denied or discredited the links between football and such brain damage for months or even years. The roughly 20 cases of C.T.E. that have been identified by groups at Boston University and West Virginia University were almost always men who had died — most with significant emotional or cognitive problems — with no knowledge of the disease. Now, for the first time he knows of, Stern said, a former player has killed himself with the specific request that his brain be examined.

I'm left to wonder, did this former football player have this problem? Sometimes depression alone causes memory problems and sometimes people with depression worry that they have Alzheimer's disease, or any number of other illnesses for that matter. Treating the depression may help the memory problems, and may alleviate the fears of other illnesses. And we don't know much about the Chronic Traumatic Encephelopathy induced by repeated head injuries: is the course of the dementia altered by early intervention with medications? Does the depression respond to the usual treatments for mood disorders? Could Mr. Duerson have been saved, at least for a while?

Here's an article on the treatment of chronic brain injury with hyperbaric oxygen in animal models:
http://www.hbot.com/first-successful-treatment-of-chronic-traumatic-brain-injury

And here's an emedicine article on treatments for repetitive brain injuries (not necessarily specific to CTE) with medicine recommendations, but no mention of antidepressants or medicines to slow the course of dementia:
http://emedicine.medscape.com/article/92189-treatment

Here's a medscape article on CTE and dementia:
http://www.alzheimersreadingroom.com/2010/08/causes-of-dementia-chronic-traumatic.html

And, finally, here's a shout out to my friend and med school classmate Robert Morrison, M.D., Ph.D. whose paper for our public health class was published in JAMA back in 1986 as a state of the art review of boxing and brain injury: http://jama.ama-assn.org/content/255/18/2475.short

Is it worth it in the name of sports?

Could I ask a huge favor of the next football player who considers suicide? Instead of completing the act, could you have your depression treated and then write about the results? It would be an enormous contribution. Sure, it would be an anecdote, and not a controlled trial, but perhaps it would add something to the field. And we'd be happy to publish your story here on Shrink Rap.

My heart goes out to the family of Dave Duerson.