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Masterclass: Major Depression with Joseph Goldberg
Dr. Goldberg is a clinical professor of psychiatry at the Ichan school of medicine at Mount Sinai in New York City.
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Dr. Goldberg is a clinical professor of psychiatry at the Ichan school of medicine at Mount Sinai in New York City.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Dr. Goldberg is a clinical professor of psychiatry at the Ichan school of medicine at Mount Sinai in New York City.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Liquid nicotine in e-cigarettes could prove more addictive; gratitude tied to less anxiety, depression
The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking,
“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.
Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”
Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.
And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.
“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”
In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
Impact of gratitude on the brain
The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.
“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.
A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.
Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.
Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
Did talk radio host save a life?
Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.
Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”
The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.
When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
A trip to Walmart can include therapy
A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.
“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”
Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.
The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.
Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.
Smartphones and the teenage brain
The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).
A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.
But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.
The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking,
“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.
Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”
Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.
And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.
“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”
In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
Impact of gratitude on the brain
The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.
“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.
A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.
Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.
Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
Did talk radio host save a life?
Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.
Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”
The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.
When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
A trip to Walmart can include therapy
A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.
“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”
Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.
The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.
Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.
Smartphones and the teenage brain
The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).
A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.
But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.
The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking,
“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.
Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”
Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.
And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.
“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”
In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
Impact of gratitude on the brain
The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.
“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.
A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.
Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.
Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
Did talk radio host save a life?
Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.
Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”
The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.
When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
A trip to Walmart can include therapy
A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.
“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”
Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.
The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.
Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.
Smartphones and the teenage brain
The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).
A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.
But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.
Report criticizes VA’s suicide prevention efforts; author shares depression-fighting strategies
The suicide rate among veterans is almost double that of the general American population. It has been rising among those who served in the wars in Iraq and Afghanistan.
Rep. Tim Walz, the Minnesota Democrat who requested the investigation, reportedly said in a statement. “Unfortunately, VA failed to do that.”
Mr. Walz was referring to a failure in prevention efforts that was detailed in a Government Accountability Office report released recently and was the subject of an article in the New York Times. The report blames bureaucratic confusion and an absence of leadership – epitomized by several department vacancies.
“This is such an important issue; we need to be throwing everything we can at it,” said Caitin Thompson, PhD. She was director of the VA’s suicide prevention efforts but resigned in frustration in mid-2017. “It’s so ludicrous that money would be sitting on the table. Outreach is one of the first ways to engage with veterans and families about ways to get help. If we don’t have that, what do we have?”
Surviving the holidays with depression
The postcard image of the Christmas season is that of joyous celebration with family and friends. For many people, however, this image is false. Many complain about feelings of stress imposed by familial obligations, pressure to conform to those postcard myths, and the financial toll that all of that holiday largesse can exact.
Now add depression to this mix. How can those burdened by depression find some joy at this time of year? In a recent article in the Huffington Post, author Andrea Loewen advises staying away from social media and focusing on the positive.
“[Social media] is a double-edged sword: Either I see all the amazing things everyone else is doing and feel jealous/insignificant/left out, or I see that no one else is really posting and assume they must be too busy having incredible quality time with their families while I’m the unengaged loser scrolling Instagram,” Ms. Loewen wrote. “Either way, it’s bad news.”
One concrete practice that she engages in is taking a few minutes to think about and write down the positive things that happened each day.
“The list includes everything, big and small: from the thoughtful gift I wasn’t expecting to the simple observation that a friend seemed happy to see me,” Ms. Loewen wrote. “Depending on where I’m at in my depression, those seemingly tiny details can be vital reminders I hold a valuable place in the world.”
Artist perpetuates persistent myth
In some ways, Kanye West embraces his diagnosis of bipolar disorder. He calls the illness his “superpower,” and the art on his new album, “Ye,” includes the phrase: “I hate being Bi-Polar/it’s awesome.” But his decision to abandon his medications promotes a myth, Amanda Mull wrote in an opinion piece in the Atlantic.
“In apparently quitting his psychiatric medication for the sake of his creativity, Mr. West is promoting one of mental health’s most persistent and dangerous myths: that suffering is necessary for great art,” Ms. Mull wrote.
Philip R. Muskin, MD, who is affiliated with the department of psychiatry at Columbia University in New York, agreed that linking mental turmoil with creative genius is indeed problematic. “Creative people are not creative when they’re depressed, or so manic that no one can tolerate being with them and they start to merge into psychosis, or when they’re filled with numbing anxiety,” he said in the Atlantic article.
Esmé Weijun Wang concurred and offered a counterview to that of Mr. West. A novelist who has written about living with schizoaffective disorder, she said: “It may be true that mental illness has given me insights with which to work, creatively speaking, but it’s also made me too sick to use that creativity. The voice in my head that says, ‘Die, die, die’ is not a voice that encourages putting together a short story.”
For his part, Mr. West’s decision to stop taking his medicine threatens to undermine his own mental health. And his public musings could drive others away from treatment.
“Antiopioid backlash” causes pain
An article by Fox News has highlighted the daily toll that opioid addiction is exacting on Americans. Government efforts aimed at quelling the use of opioids by targeting availability have had the unintended consequence of the cut-off of prescriptions by many physicians. With that route turned off, many people are turning to other sources for pain relief – or are being left with no relief.
One person in the article related how his wife is unable to obtain pain relief for her neurologic and spinal diseases. “A welcome death has become a discussion,” he said.
Meanwhile, a 69-year-old veteran said the Department of Veterans Affairs ended his pain medication. “I now buy heroin on the street.”
Another person in the article, Herb Erne III, wrote: “As a nurse, I have seen addicts and the other end of opioid abuse. But there is another side to this crisis that people are not talking about, those that actually need pain medications but cannot get them because of the ‘fear factor’ of running afoul of the antiopioid – including legal ones taken safely under medical supervision – backlash.
“The chronically ill who do not abuse, who do not divert, have become the unintended victims of misguided and overzealous efforts by policy- and regulation-making bodies in the government,” he said.
Grandparents filling void
An article in the Detroit News reported on more carnage of the opioid crisis. In Michigan and elsewhere nationwide, increasing numbers of parents with opioid addiction are unable to safely care for their children or have died because of an overdose. Grandparents are stepping in to assume care.
Results of a national survey involving more than 1,000 grandparents found that 20% are the daily caregivers to their grandchildren. They can be on their own, without any financial aid from state or national programs. Other children without grandparents can be diverted to foster care.
It’s a role few grandparents anticipated. “Our system as a whole is messed up. It tears at my heart,” 47-year-old Christina Wasilewski said in the article. “Everyone keeps saying children are resilient, but only to a point.”
Ms. Wasilewski and her husband assumed care for their granddaughter when they discovered her in physical distress from lack of care.
In Michigan, the increase in the rate of opioid-related deaths slowed in 2017 but deaths still rose 9% from 2016 , according to the Michigan Department of Health & Human Services. The prior year the death rate was 35%. In Michigan, grandparents raising their grandchildren do not have legal parental rights for this care, including the right to seek medical care and to pursue educational options.
Ms. Wasilewski’s concern about these trends led her to launch the Caregiver Cafe, a support group for grandparents raising their grandchildren.
The suicide rate among veterans is almost double that of the general American population. It has been rising among those who served in the wars in Iraq and Afghanistan.
Rep. Tim Walz, the Minnesota Democrat who requested the investigation, reportedly said in a statement. “Unfortunately, VA failed to do that.”
Mr. Walz was referring to a failure in prevention efforts that was detailed in a Government Accountability Office report released recently and was the subject of an article in the New York Times. The report blames bureaucratic confusion and an absence of leadership – epitomized by several department vacancies.
“This is such an important issue; we need to be throwing everything we can at it,” said Caitin Thompson, PhD. She was director of the VA’s suicide prevention efforts but resigned in frustration in mid-2017. “It’s so ludicrous that money would be sitting on the table. Outreach is one of the first ways to engage with veterans and families about ways to get help. If we don’t have that, what do we have?”
Surviving the holidays with depression
The postcard image of the Christmas season is that of joyous celebration with family and friends. For many people, however, this image is false. Many complain about feelings of stress imposed by familial obligations, pressure to conform to those postcard myths, and the financial toll that all of that holiday largesse can exact.
Now add depression to this mix. How can those burdened by depression find some joy at this time of year? In a recent article in the Huffington Post, author Andrea Loewen advises staying away from social media and focusing on the positive.
“[Social media] is a double-edged sword: Either I see all the amazing things everyone else is doing and feel jealous/insignificant/left out, or I see that no one else is really posting and assume they must be too busy having incredible quality time with their families while I’m the unengaged loser scrolling Instagram,” Ms. Loewen wrote. “Either way, it’s bad news.”
One concrete practice that she engages in is taking a few minutes to think about and write down the positive things that happened each day.
“The list includes everything, big and small: from the thoughtful gift I wasn’t expecting to the simple observation that a friend seemed happy to see me,” Ms. Loewen wrote. “Depending on where I’m at in my depression, those seemingly tiny details can be vital reminders I hold a valuable place in the world.”
Artist perpetuates persistent myth
In some ways, Kanye West embraces his diagnosis of bipolar disorder. He calls the illness his “superpower,” and the art on his new album, “Ye,” includes the phrase: “I hate being Bi-Polar/it’s awesome.” But his decision to abandon his medications promotes a myth, Amanda Mull wrote in an opinion piece in the Atlantic.
“In apparently quitting his psychiatric medication for the sake of his creativity, Mr. West is promoting one of mental health’s most persistent and dangerous myths: that suffering is necessary for great art,” Ms. Mull wrote.
Philip R. Muskin, MD, who is affiliated with the department of psychiatry at Columbia University in New York, agreed that linking mental turmoil with creative genius is indeed problematic. “Creative people are not creative when they’re depressed, or so manic that no one can tolerate being with them and they start to merge into psychosis, or when they’re filled with numbing anxiety,” he said in the Atlantic article.
Esmé Weijun Wang concurred and offered a counterview to that of Mr. West. A novelist who has written about living with schizoaffective disorder, she said: “It may be true that mental illness has given me insights with which to work, creatively speaking, but it’s also made me too sick to use that creativity. The voice in my head that says, ‘Die, die, die’ is not a voice that encourages putting together a short story.”
For his part, Mr. West’s decision to stop taking his medicine threatens to undermine his own mental health. And his public musings could drive others away from treatment.
“Antiopioid backlash” causes pain
An article by Fox News has highlighted the daily toll that opioid addiction is exacting on Americans. Government efforts aimed at quelling the use of opioids by targeting availability have had the unintended consequence of the cut-off of prescriptions by many physicians. With that route turned off, many people are turning to other sources for pain relief – or are being left with no relief.
One person in the article related how his wife is unable to obtain pain relief for her neurologic and spinal diseases. “A welcome death has become a discussion,” he said.
Meanwhile, a 69-year-old veteran said the Department of Veterans Affairs ended his pain medication. “I now buy heroin on the street.”
Another person in the article, Herb Erne III, wrote: “As a nurse, I have seen addicts and the other end of opioid abuse. But there is another side to this crisis that people are not talking about, those that actually need pain medications but cannot get them because of the ‘fear factor’ of running afoul of the antiopioid – including legal ones taken safely under medical supervision – backlash.
“The chronically ill who do not abuse, who do not divert, have become the unintended victims of misguided and overzealous efforts by policy- and regulation-making bodies in the government,” he said.
Grandparents filling void
An article in the Detroit News reported on more carnage of the opioid crisis. In Michigan and elsewhere nationwide, increasing numbers of parents with opioid addiction are unable to safely care for their children or have died because of an overdose. Grandparents are stepping in to assume care.
Results of a national survey involving more than 1,000 grandparents found that 20% are the daily caregivers to their grandchildren. They can be on their own, without any financial aid from state or national programs. Other children without grandparents can be diverted to foster care.
It’s a role few grandparents anticipated. “Our system as a whole is messed up. It tears at my heart,” 47-year-old Christina Wasilewski said in the article. “Everyone keeps saying children are resilient, but only to a point.”
Ms. Wasilewski and her husband assumed care for their granddaughter when they discovered her in physical distress from lack of care.
In Michigan, the increase in the rate of opioid-related deaths slowed in 2017 but deaths still rose 9% from 2016 , according to the Michigan Department of Health & Human Services. The prior year the death rate was 35%. In Michigan, grandparents raising their grandchildren do not have legal parental rights for this care, including the right to seek medical care and to pursue educational options.
Ms. Wasilewski’s concern about these trends led her to launch the Caregiver Cafe, a support group for grandparents raising their grandchildren.
The suicide rate among veterans is almost double that of the general American population. It has been rising among those who served in the wars in Iraq and Afghanistan.
Rep. Tim Walz, the Minnesota Democrat who requested the investigation, reportedly said in a statement. “Unfortunately, VA failed to do that.”
Mr. Walz was referring to a failure in prevention efforts that was detailed in a Government Accountability Office report released recently and was the subject of an article in the New York Times. The report blames bureaucratic confusion and an absence of leadership – epitomized by several department vacancies.
“This is such an important issue; we need to be throwing everything we can at it,” said Caitin Thompson, PhD. She was director of the VA’s suicide prevention efforts but resigned in frustration in mid-2017. “It’s so ludicrous that money would be sitting on the table. Outreach is one of the first ways to engage with veterans and families about ways to get help. If we don’t have that, what do we have?”
Surviving the holidays with depression
The postcard image of the Christmas season is that of joyous celebration with family and friends. For many people, however, this image is false. Many complain about feelings of stress imposed by familial obligations, pressure to conform to those postcard myths, and the financial toll that all of that holiday largesse can exact.
Now add depression to this mix. How can those burdened by depression find some joy at this time of year? In a recent article in the Huffington Post, author Andrea Loewen advises staying away from social media and focusing on the positive.
“[Social media] is a double-edged sword: Either I see all the amazing things everyone else is doing and feel jealous/insignificant/left out, or I see that no one else is really posting and assume they must be too busy having incredible quality time with their families while I’m the unengaged loser scrolling Instagram,” Ms. Loewen wrote. “Either way, it’s bad news.”
One concrete practice that she engages in is taking a few minutes to think about and write down the positive things that happened each day.
“The list includes everything, big and small: from the thoughtful gift I wasn’t expecting to the simple observation that a friend seemed happy to see me,” Ms. Loewen wrote. “Depending on where I’m at in my depression, those seemingly tiny details can be vital reminders I hold a valuable place in the world.”
Artist perpetuates persistent myth
In some ways, Kanye West embraces his diagnosis of bipolar disorder. He calls the illness his “superpower,” and the art on his new album, “Ye,” includes the phrase: “I hate being Bi-Polar/it’s awesome.” But his decision to abandon his medications promotes a myth, Amanda Mull wrote in an opinion piece in the Atlantic.
“In apparently quitting his psychiatric medication for the sake of his creativity, Mr. West is promoting one of mental health’s most persistent and dangerous myths: that suffering is necessary for great art,” Ms. Mull wrote.
Philip R. Muskin, MD, who is affiliated with the department of psychiatry at Columbia University in New York, agreed that linking mental turmoil with creative genius is indeed problematic. “Creative people are not creative when they’re depressed, or so manic that no one can tolerate being with them and they start to merge into psychosis, or when they’re filled with numbing anxiety,” he said in the Atlantic article.
Esmé Weijun Wang concurred and offered a counterview to that of Mr. West. A novelist who has written about living with schizoaffective disorder, she said: “It may be true that mental illness has given me insights with which to work, creatively speaking, but it’s also made me too sick to use that creativity. The voice in my head that says, ‘Die, die, die’ is not a voice that encourages putting together a short story.”
For his part, Mr. West’s decision to stop taking his medicine threatens to undermine his own mental health. And his public musings could drive others away from treatment.
“Antiopioid backlash” causes pain
An article by Fox News has highlighted the daily toll that opioid addiction is exacting on Americans. Government efforts aimed at quelling the use of opioids by targeting availability have had the unintended consequence of the cut-off of prescriptions by many physicians. With that route turned off, many people are turning to other sources for pain relief – or are being left with no relief.
One person in the article related how his wife is unable to obtain pain relief for her neurologic and spinal diseases. “A welcome death has become a discussion,” he said.
Meanwhile, a 69-year-old veteran said the Department of Veterans Affairs ended his pain medication. “I now buy heroin on the street.”
Another person in the article, Herb Erne III, wrote: “As a nurse, I have seen addicts and the other end of opioid abuse. But there is another side to this crisis that people are not talking about, those that actually need pain medications but cannot get them because of the ‘fear factor’ of running afoul of the antiopioid – including legal ones taken safely under medical supervision – backlash.
“The chronically ill who do not abuse, who do not divert, have become the unintended victims of misguided and overzealous efforts by policy- and regulation-making bodies in the government,” he said.
Grandparents filling void
An article in the Detroit News reported on more carnage of the opioid crisis. In Michigan and elsewhere nationwide, increasing numbers of parents with opioid addiction are unable to safely care for their children or have died because of an overdose. Grandparents are stepping in to assume care.
Results of a national survey involving more than 1,000 grandparents found that 20% are the daily caregivers to their grandchildren. They can be on their own, without any financial aid from state or national programs. Other children without grandparents can be diverted to foster care.
It’s a role few grandparents anticipated. “Our system as a whole is messed up. It tears at my heart,” 47-year-old Christina Wasilewski said in the article. “Everyone keeps saying children are resilient, but only to a point.”
Ms. Wasilewski and her husband assumed care for their granddaughter when they discovered her in physical distress from lack of care.
In Michigan, the increase in the rate of opioid-related deaths slowed in 2017 but deaths still rose 9% from 2016 , according to the Michigan Department of Health & Human Services. The prior year the death rate was 35%. In Michigan, grandparents raising their grandchildren do not have legal parental rights for this care, including the right to seek medical care and to pursue educational options.
Ms. Wasilewski’s concern about these trends led her to launch the Caregiver Cafe, a support group for grandparents raising their grandchildren.
Michigan police receive training to recognize mental illness
Responding to a police call can prove dangerous. In those kinds of high-pressure situations, agitation or other manifestations of mental illness might be mistaken for violent intent – with disastrous results.
In Kalamazoo, Mich., crime response training now includes subduing suspects without using violent force. “Through training and education, and scenarios that we use in the training, [the officers] start to detect the different cues or indicators where they start to see that this is really a crisis event. And we treat it as a medical issue and get that person the help that they need,” said Rafael Diaz, executive lieutenant with the Kalamazoo Department of Public Safety in an interview on Michigan NPR.
In the training, called the Crisis Intervention Team model, the goal is to slow down the pace of the interaction and keep some distance between themselves and the suspect after officers recognize signs of mental illness. Both responses can lower the chances of a lash-out response.
“The number of injuries to officers goes down, the number of injuries to the person in crisis goes down, and there is a huge benefit to society there if you don’t have to use physical force,” Mr. Diaz said.
Animal neglect and mental health
Images of neglected and abused livestock on farms can inspire thoughts of how someone could mistreat the animals in their care. “Frankly, if you can’t understand that, it’s probably a good thing. It means you haven’t been in the depths of low, low mental health, depression, and anxiety,” Andria Jones-Bitton, DVM, PhD, said in an interview with the Western Producer.
Dr. Jones-Bitton is a veterinarian and epidemiologist at the Ontario Veterinary College in Guelph. She is studying the mental health and mental resilience of farmers and veterinarians.
“If farmers are struggling with their own well-being and motivation, they’re likely going to find it difficult to invest in improving animal welfare. When we’re mentally unwell, it’s hard to care for ourselves, let alone to care for others, even when those others are really important to us,” she said.
A national survey of Canadian farmers by Dr. Jones-Bitton showed high levels of stress and diminished ability to cope with the pressures that come with running a livestock farm. “What makes me the most upset is I have everything I’ve ever dreamed of – love, family, and a farm, and all I feel is overwhelmed out of control and sad,” one respondent said.
The problems are not unique to Canada. Studies from Ireland, for example, documented an association between animal neglect cases and the mental health, drug/alcohol addiction, and social problems of farmers.
“Even if you didn’t care about the humans that were struggling and you only cared about the animal welfare, you’d be wise to address the issue of farmer stress,” Dr. Jones-Britton said.
Depression and rural America
A recent “Farming in Tough Times” workshop that convened in Minnesota focused on the mental health of farmers. Making a living is challenging for many reasons. One is that prices for commodities are set by others.
“I realized that I can’t change the situation that we’re in. I can’t change milk prices. I can’t stop farms from going bankrupt. But I can change how we are. And we are together, and that really does matter,” said dairy farmer Brenda Rudolph during the workshop, according to a report from the St. Cloud Times, which is part of the USA Today network.
“There is a conversation you people have to have in America, rural America, that says, depression is part of your life. It is not a sign of weakness. It’s a sign of reality,” said Dennis Hoiberg, a farming consultant based in Australia who spoke at the workshop. He added that, from his perspective, the United States still tends to be more repressed about mental health issues than elsewhere in the world – with the focus on stress and not on resiliency.
“Most of you folk are proud folk, and most you folk are very proud of what you do,” Mr. Hoiberg said. “You’re also psychologically exposed because you are a true believer [in what you do].”
Advice offered to lessen the tough times included noticing the beauty in the world, breaking down problems into small chunks that are more easily dealt with and then moving on to the next, sleep, and a good diet.
People with mental illness languishing
Public defenders in Colorado are seeking to have dozens of people diagnosed with mental illness who are in jail awaiting trial set free until their court date. The usual scenario in Colorado for someone charged with a crime and jailed who is deemed mentally incompetent is treatment within 28 days. However, this system is broken and wait times are far longer – in one instance 270 days.
“Many of them are there for very, very low level offenses and they’re holding in jail for way longer than a person who did not suffer from mental illness would be in custody,” said Maureen Cain, policy liaison for the public defender’s office in an interview with the Denver Post. “They are being incarcerated for their mental illness, not really because of the crime they committed.” Responses from judges have ranged from immediate release to finding the incarcerated person guilty of contempt and sending them back to jail.
The Colorado Department of Human Services is in charge of people who have been jailed but have been found to be incompetent to stand trial. Officials there have say they do not have enough bed space or capacity to get people moved out of jail within 28 days.
“We are in a situation where [the human services department] is in breach, and I need to know what efforts are being made to bring it back into compliance,” said federal Judge Nina Y. Wang. “These individuals are not being served, and frankly, the state is not being served.”
“Cruel” practice confined youth
A federal class action lawsuit filed against the Departmental of Children and Family Services (DCFS) in the Chicago area alleges that, from 2015 to 2017, more than 800 youth were being confined to psychiatric hospitals even when they were cleared for discharge. The problem goes back decades and is getting worse, the lawsuit contends.
“I spent Thanksgiving, Christmas, New Year’s, Easter, and my 16th birthday in the hospital,” said Skylar, who’s now 19 years old. “I only got to go outside one time. I felt like a prisoner; I felt very depressed.”
As reported on Chicago’s WGN9 News, the delay between clearance for discharge and actual freedom is a month or more in many of the cases. Acting Cook County Public Guardian Charles Golbert said the practice is “cruel, unusual, and illegal. It’s a violation of the children’s civil and most basic human rights.”
Many of the youth had been incarcerated for setting fires and self-harm and had been rejected by foster parents and other providers, in some cases their own families, who were concerned with the possible behavior of the youth after their release.
“Blame the children is the wrong response from DCFS,” said attorney Russell Ainsworth. “DCFS should be apologizing for not addressing this issue and for violating the Constitution.”
Responding to a police call can prove dangerous. In those kinds of high-pressure situations, agitation or other manifestations of mental illness might be mistaken for violent intent – with disastrous results.
In Kalamazoo, Mich., crime response training now includes subduing suspects without using violent force. “Through training and education, and scenarios that we use in the training, [the officers] start to detect the different cues or indicators where they start to see that this is really a crisis event. And we treat it as a medical issue and get that person the help that they need,” said Rafael Diaz, executive lieutenant with the Kalamazoo Department of Public Safety in an interview on Michigan NPR.
In the training, called the Crisis Intervention Team model, the goal is to slow down the pace of the interaction and keep some distance between themselves and the suspect after officers recognize signs of mental illness. Both responses can lower the chances of a lash-out response.
“The number of injuries to officers goes down, the number of injuries to the person in crisis goes down, and there is a huge benefit to society there if you don’t have to use physical force,” Mr. Diaz said.
Animal neglect and mental health
Images of neglected and abused livestock on farms can inspire thoughts of how someone could mistreat the animals in their care. “Frankly, if you can’t understand that, it’s probably a good thing. It means you haven’t been in the depths of low, low mental health, depression, and anxiety,” Andria Jones-Bitton, DVM, PhD, said in an interview with the Western Producer.
Dr. Jones-Bitton is a veterinarian and epidemiologist at the Ontario Veterinary College in Guelph. She is studying the mental health and mental resilience of farmers and veterinarians.
“If farmers are struggling with their own well-being and motivation, they’re likely going to find it difficult to invest in improving animal welfare. When we’re mentally unwell, it’s hard to care for ourselves, let alone to care for others, even when those others are really important to us,” she said.
A national survey of Canadian farmers by Dr. Jones-Bitton showed high levels of stress and diminished ability to cope with the pressures that come with running a livestock farm. “What makes me the most upset is I have everything I’ve ever dreamed of – love, family, and a farm, and all I feel is overwhelmed out of control and sad,” one respondent said.
The problems are not unique to Canada. Studies from Ireland, for example, documented an association between animal neglect cases and the mental health, drug/alcohol addiction, and social problems of farmers.
“Even if you didn’t care about the humans that were struggling and you only cared about the animal welfare, you’d be wise to address the issue of farmer stress,” Dr. Jones-Britton said.
Depression and rural America
A recent “Farming in Tough Times” workshop that convened in Minnesota focused on the mental health of farmers. Making a living is challenging for many reasons. One is that prices for commodities are set by others.
“I realized that I can’t change the situation that we’re in. I can’t change milk prices. I can’t stop farms from going bankrupt. But I can change how we are. And we are together, and that really does matter,” said dairy farmer Brenda Rudolph during the workshop, according to a report from the St. Cloud Times, which is part of the USA Today network.
“There is a conversation you people have to have in America, rural America, that says, depression is part of your life. It is not a sign of weakness. It’s a sign of reality,” said Dennis Hoiberg, a farming consultant based in Australia who spoke at the workshop. He added that, from his perspective, the United States still tends to be more repressed about mental health issues than elsewhere in the world – with the focus on stress and not on resiliency.
“Most of you folk are proud folk, and most you folk are very proud of what you do,” Mr. Hoiberg said. “You’re also psychologically exposed because you are a true believer [in what you do].”
Advice offered to lessen the tough times included noticing the beauty in the world, breaking down problems into small chunks that are more easily dealt with and then moving on to the next, sleep, and a good diet.
People with mental illness languishing
Public defenders in Colorado are seeking to have dozens of people diagnosed with mental illness who are in jail awaiting trial set free until their court date. The usual scenario in Colorado for someone charged with a crime and jailed who is deemed mentally incompetent is treatment within 28 days. However, this system is broken and wait times are far longer – in one instance 270 days.
“Many of them are there for very, very low level offenses and they’re holding in jail for way longer than a person who did not suffer from mental illness would be in custody,” said Maureen Cain, policy liaison for the public defender’s office in an interview with the Denver Post. “They are being incarcerated for their mental illness, not really because of the crime they committed.” Responses from judges have ranged from immediate release to finding the incarcerated person guilty of contempt and sending them back to jail.
The Colorado Department of Human Services is in charge of people who have been jailed but have been found to be incompetent to stand trial. Officials there have say they do not have enough bed space or capacity to get people moved out of jail within 28 days.
“We are in a situation where [the human services department] is in breach, and I need to know what efforts are being made to bring it back into compliance,” said federal Judge Nina Y. Wang. “These individuals are not being served, and frankly, the state is not being served.”
“Cruel” practice confined youth
A federal class action lawsuit filed against the Departmental of Children and Family Services (DCFS) in the Chicago area alleges that, from 2015 to 2017, more than 800 youth were being confined to psychiatric hospitals even when they were cleared for discharge. The problem goes back decades and is getting worse, the lawsuit contends.
“I spent Thanksgiving, Christmas, New Year’s, Easter, and my 16th birthday in the hospital,” said Skylar, who’s now 19 years old. “I only got to go outside one time. I felt like a prisoner; I felt very depressed.”
As reported on Chicago’s WGN9 News, the delay between clearance for discharge and actual freedom is a month or more in many of the cases. Acting Cook County Public Guardian Charles Golbert said the practice is “cruel, unusual, and illegal. It’s a violation of the children’s civil and most basic human rights.”
Many of the youth had been incarcerated for setting fires and self-harm and had been rejected by foster parents and other providers, in some cases their own families, who were concerned with the possible behavior of the youth after their release.
“Blame the children is the wrong response from DCFS,” said attorney Russell Ainsworth. “DCFS should be apologizing for not addressing this issue and for violating the Constitution.”
Responding to a police call can prove dangerous. In those kinds of high-pressure situations, agitation or other manifestations of mental illness might be mistaken for violent intent – with disastrous results.
In Kalamazoo, Mich., crime response training now includes subduing suspects without using violent force. “Through training and education, and scenarios that we use in the training, [the officers] start to detect the different cues or indicators where they start to see that this is really a crisis event. And we treat it as a medical issue and get that person the help that they need,” said Rafael Diaz, executive lieutenant with the Kalamazoo Department of Public Safety in an interview on Michigan NPR.
In the training, called the Crisis Intervention Team model, the goal is to slow down the pace of the interaction and keep some distance between themselves and the suspect after officers recognize signs of mental illness. Both responses can lower the chances of a lash-out response.
“The number of injuries to officers goes down, the number of injuries to the person in crisis goes down, and there is a huge benefit to society there if you don’t have to use physical force,” Mr. Diaz said.
Animal neglect and mental health
Images of neglected and abused livestock on farms can inspire thoughts of how someone could mistreat the animals in their care. “Frankly, if you can’t understand that, it’s probably a good thing. It means you haven’t been in the depths of low, low mental health, depression, and anxiety,” Andria Jones-Bitton, DVM, PhD, said in an interview with the Western Producer.
Dr. Jones-Bitton is a veterinarian and epidemiologist at the Ontario Veterinary College in Guelph. She is studying the mental health and mental resilience of farmers and veterinarians.
“If farmers are struggling with their own well-being and motivation, they’re likely going to find it difficult to invest in improving animal welfare. When we’re mentally unwell, it’s hard to care for ourselves, let alone to care for others, even when those others are really important to us,” she said.
A national survey of Canadian farmers by Dr. Jones-Bitton showed high levels of stress and diminished ability to cope with the pressures that come with running a livestock farm. “What makes me the most upset is I have everything I’ve ever dreamed of – love, family, and a farm, and all I feel is overwhelmed out of control and sad,” one respondent said.
The problems are not unique to Canada. Studies from Ireland, for example, documented an association between animal neglect cases and the mental health, drug/alcohol addiction, and social problems of farmers.
“Even if you didn’t care about the humans that were struggling and you only cared about the animal welfare, you’d be wise to address the issue of farmer stress,” Dr. Jones-Britton said.
Depression and rural America
A recent “Farming in Tough Times” workshop that convened in Minnesota focused on the mental health of farmers. Making a living is challenging for many reasons. One is that prices for commodities are set by others.
“I realized that I can’t change the situation that we’re in. I can’t change milk prices. I can’t stop farms from going bankrupt. But I can change how we are. And we are together, and that really does matter,” said dairy farmer Brenda Rudolph during the workshop, according to a report from the St. Cloud Times, which is part of the USA Today network.
“There is a conversation you people have to have in America, rural America, that says, depression is part of your life. It is not a sign of weakness. It’s a sign of reality,” said Dennis Hoiberg, a farming consultant based in Australia who spoke at the workshop. He added that, from his perspective, the United States still tends to be more repressed about mental health issues than elsewhere in the world – with the focus on stress and not on resiliency.
“Most of you folk are proud folk, and most you folk are very proud of what you do,” Mr. Hoiberg said. “You’re also psychologically exposed because you are a true believer [in what you do].”
Advice offered to lessen the tough times included noticing the beauty in the world, breaking down problems into small chunks that are more easily dealt with and then moving on to the next, sleep, and a good diet.
People with mental illness languishing
Public defenders in Colorado are seeking to have dozens of people diagnosed with mental illness who are in jail awaiting trial set free until their court date. The usual scenario in Colorado for someone charged with a crime and jailed who is deemed mentally incompetent is treatment within 28 days. However, this system is broken and wait times are far longer – in one instance 270 days.
“Many of them are there for very, very low level offenses and they’re holding in jail for way longer than a person who did not suffer from mental illness would be in custody,” said Maureen Cain, policy liaison for the public defender’s office in an interview with the Denver Post. “They are being incarcerated for their mental illness, not really because of the crime they committed.” Responses from judges have ranged from immediate release to finding the incarcerated person guilty of contempt and sending them back to jail.
The Colorado Department of Human Services is in charge of people who have been jailed but have been found to be incompetent to stand trial. Officials there have say they do not have enough bed space or capacity to get people moved out of jail within 28 days.
“We are in a situation where [the human services department] is in breach, and I need to know what efforts are being made to bring it back into compliance,” said federal Judge Nina Y. Wang. “These individuals are not being served, and frankly, the state is not being served.”
“Cruel” practice confined youth
A federal class action lawsuit filed against the Departmental of Children and Family Services (DCFS) in the Chicago area alleges that, from 2015 to 2017, more than 800 youth were being confined to psychiatric hospitals even when they were cleared for discharge. The problem goes back decades and is getting worse, the lawsuit contends.
“I spent Thanksgiving, Christmas, New Year’s, Easter, and my 16th birthday in the hospital,” said Skylar, who’s now 19 years old. “I only got to go outside one time. I felt like a prisoner; I felt very depressed.”
As reported on Chicago’s WGN9 News, the delay between clearance for discharge and actual freedom is a month or more in many of the cases. Acting Cook County Public Guardian Charles Golbert said the practice is “cruel, unusual, and illegal. It’s a violation of the children’s civil and most basic human rights.”
Many of the youth had been incarcerated for setting fires and self-harm and had been rejected by foster parents and other providers, in some cases their own families, who were concerned with the possible behavior of the youth after their release.
“Blame the children is the wrong response from DCFS,” said attorney Russell Ainsworth. “DCFS should be apologizing for not addressing this issue and for violating the Constitution.”
Atopic dermatitis associated with increased suicidality
Patients with atopic dermatitis might face up to a 44% increased risk of suicidal ideation and are 36% more likely to attempt suicide than those without the disorder, a large meta-analysis has determined.
The analysis, which included data from studies published as far back as 1945, also found some correlation of increased suicide risk and increasing disease severity, although the numbers were small, Jeena K. Sandhu and her colleagues reported in JAMA Dermatology.
Both physical and psychological factors could be involved in the link, wrote Ms. Sandhu, a medical student at the University of Missouri–Kansas City, and her coauthors.
“Atopic dermatitis is associated with multiple physical comorbidities, such as asthma, allergic rhinitis, metabolic syndrome, and sleep disturbances, which all contribute to the overall physical burden of the disease. Many patients also have a profound psychosocial burden. Because of the visibility of the disease, patients may experience shame, embarrassment, and stigmatization,” they wrote.
But the disease also is associated with high levels of proinflammatory cytokines, and those proteins have been isolated in the cerebrospinal fluid of patients who have attempted suicide, the investigators noted. “Treatments targeting cytokines, such as interleukin-4 and interleukin-13, have been shown to decrease symptoms of depression and anxiety in patients with atopic dermatitis.”
The investigators plumbed several databases of medical literature, searching for studies that mentioned both atopic dermatitis (AD) and suicide, suicidal ideation, or suicidal behavior. They found 15 studies, published from 1945 to May 2018. Most (13) were cross sectional; the remainder were cohort studies. Together, they comprised a total of 4.7 million subjects, 310,681 of whom had AD. The analysis looked at risks in three areas: suicidal ideation, suicide attempts, and completed suicides.
Of the studies, 11 investigated suicidal ideation. Pooled data determined that patients with AD were a significant 44% more likely to experience suicidal ideation than those without the disease.
Three studies mentioned suicide attempts and had complete data for pooling. Taken together, they showed a significant 36% increased risk of attempted suicide among patients with AD, compared with those without the disorder.
Two studies investigated the prevalence of completed suicides among patients. One did report a significantly increased risk of 40%, compared with the control group, but it failed to report the number of suicides in the control group. The other study found no increased risk of completed suicides in patients with either mild or moderate to severe disease, compared with controls.
Two studies involved only pediatric patients. One, conducted in Korea, found a significant 23% increased risk of suicidal ideation and a 31% increased risk of attempted suicide. The other failed to find any increased risks in the overall analysis, but did find small increases in the risks of ideation and attempt in girls with AD, compared with healthy controls.
the team concluded. “Dermatology providers may use several tools to screen patients for suicidality. Asking patients about suicidal ideation with a question may be integrated into a patient visit. If a patient screens positive for suicidality, the dermatology provider should send a referral to the patient’s primary care or mental health provider for follow-up care. If the patient reports an orchestrated plan to commit suicide, this patient should be urgently referred to the emergency department for further assessment.”
Ms. Sandhu reported no financial disclosures.
SOURCE: Sandhu JK et al. JAMA Dermatol. 2018 Dec 12. doi: 10.1001/jamadermatol.2018.4566.
Patients with atopic dermatitis might face up to a 44% increased risk of suicidal ideation and are 36% more likely to attempt suicide than those without the disorder, a large meta-analysis has determined.
The analysis, which included data from studies published as far back as 1945, also found some correlation of increased suicide risk and increasing disease severity, although the numbers were small, Jeena K. Sandhu and her colleagues reported in JAMA Dermatology.
Both physical and psychological factors could be involved in the link, wrote Ms. Sandhu, a medical student at the University of Missouri–Kansas City, and her coauthors.
“Atopic dermatitis is associated with multiple physical comorbidities, such as asthma, allergic rhinitis, metabolic syndrome, and sleep disturbances, which all contribute to the overall physical burden of the disease. Many patients also have a profound psychosocial burden. Because of the visibility of the disease, patients may experience shame, embarrassment, and stigmatization,” they wrote.
But the disease also is associated with high levels of proinflammatory cytokines, and those proteins have been isolated in the cerebrospinal fluid of patients who have attempted suicide, the investigators noted. “Treatments targeting cytokines, such as interleukin-4 and interleukin-13, have been shown to decrease symptoms of depression and anxiety in patients with atopic dermatitis.”
The investigators plumbed several databases of medical literature, searching for studies that mentioned both atopic dermatitis (AD) and suicide, suicidal ideation, or suicidal behavior. They found 15 studies, published from 1945 to May 2018. Most (13) were cross sectional; the remainder were cohort studies. Together, they comprised a total of 4.7 million subjects, 310,681 of whom had AD. The analysis looked at risks in three areas: suicidal ideation, suicide attempts, and completed suicides.
Of the studies, 11 investigated suicidal ideation. Pooled data determined that patients with AD were a significant 44% more likely to experience suicidal ideation than those without the disease.
Three studies mentioned suicide attempts and had complete data for pooling. Taken together, they showed a significant 36% increased risk of attempted suicide among patients with AD, compared with those without the disorder.
Two studies investigated the prevalence of completed suicides among patients. One did report a significantly increased risk of 40%, compared with the control group, but it failed to report the number of suicides in the control group. The other study found no increased risk of completed suicides in patients with either mild or moderate to severe disease, compared with controls.
Two studies involved only pediatric patients. One, conducted in Korea, found a significant 23% increased risk of suicidal ideation and a 31% increased risk of attempted suicide. The other failed to find any increased risks in the overall analysis, but did find small increases in the risks of ideation and attempt in girls with AD, compared with healthy controls.
the team concluded. “Dermatology providers may use several tools to screen patients for suicidality. Asking patients about suicidal ideation with a question may be integrated into a patient visit. If a patient screens positive for suicidality, the dermatology provider should send a referral to the patient’s primary care or mental health provider for follow-up care. If the patient reports an orchestrated plan to commit suicide, this patient should be urgently referred to the emergency department for further assessment.”
Ms. Sandhu reported no financial disclosures.
SOURCE: Sandhu JK et al. JAMA Dermatol. 2018 Dec 12. doi: 10.1001/jamadermatol.2018.4566.
Patients with atopic dermatitis might face up to a 44% increased risk of suicidal ideation and are 36% more likely to attempt suicide than those without the disorder, a large meta-analysis has determined.
The analysis, which included data from studies published as far back as 1945, also found some correlation of increased suicide risk and increasing disease severity, although the numbers were small, Jeena K. Sandhu and her colleagues reported in JAMA Dermatology.
Both physical and psychological factors could be involved in the link, wrote Ms. Sandhu, a medical student at the University of Missouri–Kansas City, and her coauthors.
“Atopic dermatitis is associated with multiple physical comorbidities, such as asthma, allergic rhinitis, metabolic syndrome, and sleep disturbances, which all contribute to the overall physical burden of the disease. Many patients also have a profound psychosocial burden. Because of the visibility of the disease, patients may experience shame, embarrassment, and stigmatization,” they wrote.
But the disease also is associated with high levels of proinflammatory cytokines, and those proteins have been isolated in the cerebrospinal fluid of patients who have attempted suicide, the investigators noted. “Treatments targeting cytokines, such as interleukin-4 and interleukin-13, have been shown to decrease symptoms of depression and anxiety in patients with atopic dermatitis.”
The investigators plumbed several databases of medical literature, searching for studies that mentioned both atopic dermatitis (AD) and suicide, suicidal ideation, or suicidal behavior. They found 15 studies, published from 1945 to May 2018. Most (13) were cross sectional; the remainder were cohort studies. Together, they comprised a total of 4.7 million subjects, 310,681 of whom had AD. The analysis looked at risks in three areas: suicidal ideation, suicide attempts, and completed suicides.
Of the studies, 11 investigated suicidal ideation. Pooled data determined that patients with AD were a significant 44% more likely to experience suicidal ideation than those without the disease.
Three studies mentioned suicide attempts and had complete data for pooling. Taken together, they showed a significant 36% increased risk of attempted suicide among patients with AD, compared with those without the disorder.
Two studies investigated the prevalence of completed suicides among patients. One did report a significantly increased risk of 40%, compared with the control group, but it failed to report the number of suicides in the control group. The other study found no increased risk of completed suicides in patients with either mild or moderate to severe disease, compared with controls.
Two studies involved only pediatric patients. One, conducted in Korea, found a significant 23% increased risk of suicidal ideation and a 31% increased risk of attempted suicide. The other failed to find any increased risks in the overall analysis, but did find small increases in the risks of ideation and attempt in girls with AD, compared with healthy controls.
the team concluded. “Dermatology providers may use several tools to screen patients for suicidality. Asking patients about suicidal ideation with a question may be integrated into a patient visit. If a patient screens positive for suicidality, the dermatology provider should send a referral to the patient’s primary care or mental health provider for follow-up care. If the patient reports an orchestrated plan to commit suicide, this patient should be urgently referred to the emergency department for further assessment.”
Ms. Sandhu reported no financial disclosures.
SOURCE: Sandhu JK et al. JAMA Dermatol. 2018 Dec 12. doi: 10.1001/jamadermatol.2018.4566.
FROM JAMA DERMATOLOGY
Key clinical point: Suicidal ideation and suicide attempts seem to be more common among people with atopic dermatitis than those without the disease.
Major finding: Patients were 44% more likely to have suicidal ideation and 36% more likely to attempt suicide.
Study details: The meta-analysis comprised 15 studies with a total of 4.7 million participants, 310,681 of whom had the disease.
Disclosures: Ms. Sandhu reported no financial disclosures.
Source: Sandhu JK et al. JAMA Dermatol. 2018 Dec 12. doi: 10.1001/jamadermatol.2018.4566.
FDA reclassifies ECT devices for resistant depression, other conditions
The Food and Drug Administration issued a final order Dec. 21 reclassifying electroconvulsive therapy (ECT) devices from class III, indicating higher risk, to class II, indicating moderate risk, in certain cases.
Conditions included in the new order are catatonia or a severe major depressive episode associated with major depressive disorder or bipolar disorder in patients over the age of 13 years who are resistant to treatment or who require a rapid response because of the severity of their psychiatric or medical condition, according to an FDA press release.
In addition, the final order requires the filing of premarket approval application for class III devices used for all conditions not reclassified as class II.
“The FDA is issuing this final order to regulate ECT devices in a way that appropriately reflects the known benefits and risks of these devices for their indications for use, provides patients with additional protections, and gives physicians more information on the safe and effective use of these devices,” the agency said in the press release.
The Food and Drug Administration issued a final order Dec. 21 reclassifying electroconvulsive therapy (ECT) devices from class III, indicating higher risk, to class II, indicating moderate risk, in certain cases.
Conditions included in the new order are catatonia or a severe major depressive episode associated with major depressive disorder or bipolar disorder in patients over the age of 13 years who are resistant to treatment or who require a rapid response because of the severity of their psychiatric or medical condition, according to an FDA press release.
In addition, the final order requires the filing of premarket approval application for class III devices used for all conditions not reclassified as class II.
“The FDA is issuing this final order to regulate ECT devices in a way that appropriately reflects the known benefits and risks of these devices for their indications for use, provides patients with additional protections, and gives physicians more information on the safe and effective use of these devices,” the agency said in the press release.
The Food and Drug Administration issued a final order Dec. 21 reclassifying electroconvulsive therapy (ECT) devices from class III, indicating higher risk, to class II, indicating moderate risk, in certain cases.
Conditions included in the new order are catatonia or a severe major depressive episode associated with major depressive disorder or bipolar disorder in patients over the age of 13 years who are resistant to treatment or who require a rapid response because of the severity of their psychiatric or medical condition, according to an FDA press release.
In addition, the final order requires the filing of premarket approval application for class III devices used for all conditions not reclassified as class II.
“The FDA is issuing this final order to regulate ECT devices in a way that appropriately reflects the known benefits and risks of these devices for their indications for use, provides patients with additional protections, and gives physicians more information on the safe and effective use of these devices,” the agency said in the press release.
Medical marijuana for autism facing good prospects in Colorado
Five years after the legalization of marijuana in Colorado, anticipated legislation in 2019 could see home delivery of cannabis and cannabis-related products, and expanded medical availability.
Governor-elect Jared Polis, who takes office in the new year, probably will take a different approach from outgoing Gov. John Hickenlooper, according to a recent article in the Denver Post. Mr. Hickenlooper vetoed previous legislation intended to increase drug’s accessibility.
“ says Albert Gutierrez, CEO of MedPharm Holdings, a cannabis research and cultivation company.
“You’re going to probably have more variety from these companies, whether they’re offering drinks or chocolate bars. But these companies are going to be the household names that people are going to come to know over the next 30, 50, 100 years,” he says.
Not everyone is on board. “We should all be able to agree that Colorado’s increasingly potent marijuana products are harmful to youth and that we have a collective responsibility to protect Colorado kids,” writes Henny Lasley, the cofounder of Smart Colorado, which was formed in opposition to the legalization of marijuana in the state.
The availability of medical marijuana for people diagnosed with autism spectrum disorders is among the vetoed initiatives that are likely to reemerge in 2019. That bill reportedly was opposed by the Colorado Child and Adolescent Psychiatric Society, the Colorado Psychiatric Society, and by Larry Wolk, MD, who recently stepped down as chief medical officer of the state’s department of public health and environment.
Adjusting to life after fires
The latest wildfires have been vanquished in California. For those affected recently and in the past several years has come the reality that the draw of living on the edge of nature means living surrounded by tinder-dry terrain. It’s a great location – until it ignites.
A year ago, the Thomas Fire devastated Ventura and Santa Barbara counties, burning more than 440 square miles. Few people died, but more than 1,000 buildings were destroyed – and hundreds of people were left homeless. A year later, in the Clearpoint neighborhood of Ventura, residential lots sit empty, their owners having abandoned the effort to rebuild. Others, like Sandra and Ed Fuller, are choosing to begin again. The beauty of the area that pulled them there years ago remains strong.
They have come to terms with losing their home to the fire. “I think it was a sort of a breaking point where there was just a flood of peace that kind of went through. It’s like there is nothing we can do about this. We know what we have to do now. We’ll just get on with it,” Ed Fuller says in an interview with NPR.
Having the Christmas season looming has been a boost to their spirits and planning. “My wife is absolutely obsessed that she’s ready for Christmas. Last Christmas we sort of lost.”
The invisibility of asexuality
It can be hard for some to fathom that sex just isn’t important for some. “They are the friends and family members who don’t express any desire to pursue sexual intimacy, who don’t often or ever seem interested in conventional dating, and who get pushed to the sidelines in any conversation about sexual health,” Kate Sloan writes in a recent article in the Walrus.
“Much like same-sex attraction decades ago, this nonattraction was initially (and is sometimes still) conflated with a sexual-desire disorder, worthy of pathologization and medical treatment with pharmaceuticals or therapy. But scientists have confirmed asexuality isn’t a medical issue; it is a sexual orientation on the same plane as heterosexuality, homosexuality, and bisexuality,” Ms. Sloan writes.
“If someone is gay, as an example, it’s pretty easy to say, ‘Okay, well, I experience the same type of attraction that everyone else does, it’s just pointed at a different gender,’ ” says Brian Langevin, executive director of the nonprofit organization Asexual Outreach. “For asexual people ... they might not even know that sexual attraction exists, and to them, the whole world could seem very confusing.”
Meanwhile, a 2013 study in British Columbia showed that asexual individuals are more likely to be socially isolated, depressed, and anxious.
“True emotional intimacy is created, according to psychology, by honesty, empathy, and listening,” Ms. Sloan writes. “When we oversimplify relationships by insisting, on a sociocultural level, that sex is the ultimate key to and only sign of a profound connection, we deprive ourselves of the more holistic affinities available to us if we look for more.”
Fundamental churches face allegations
Joy Evans Ryder was 15 when she reportedly was raped by Dave Hyles, youth director at her Baptist church in Hammond, Ind. She was not the youth director’s only alleged victim. He never faced charges; in a scenario strikingly similar to that of hundreds of Roman Catholic priests, he escaped local prosecution by being moved on to other assignments.
An investigation by the Fort Worth (Tex.) Star-Telegram has unearthed a decades-old cover-up of more than 400 cases of sexual abuse at independent fundamental Baptist churches across the United States.
Former members of congregations point to the cultlike power of many independent fundamental Baptist churches and the constant pressure to never question pastors or leave the church.
“We didn’t have a compound ... but it may as well have been. Our mind was the compound,” says a former member. Some of the abused believed that if they disobeyed the pastor or left the church, God would kill them or their family.
Some independent fundamental Baptist churches preach separation from the world, nonbelievers, and Christians with other religious views. A natural outcome, according to Josh Elliott, a former member of Vineyard’s Oklahoma City church, is that for any issues, “even legal issues, you go to the pastor first, not the police. ... You don’t report to police because the pastor is the ultimate authority, not the government.”
“I see a culture where pastoral authority is taken to a level that’s beyond what the Scripture teaches,” says Tim Heck, who was a deacon at Faith Baptist Church in Wildomar, Calif., and whose daughter said she had been abused by the youth pastor there. “I think the independent fundamental Baptists have lost their way.”
Adam Lanza’s ‘separateness’ exposed
Written musings and other documents by Adam Lanza – who slaughtered 20 first-graders and six teachers at Sandy Hook Elementary School in Newtown, Conn., on Dec. 14, 2012 – have been reported by the Hartford Courant.
Adam Lanza was challenged by speech and sensory issues as a child but had a keen intellect. That potential was eclipsed in his teenage years by paranoia, disdain for relationships, and contempt for others, the documents show. Family, teachers, and counselors were aware of his isolation. And, with time, his obsessions and mental/physical deterioration grew. But the documents make clear that no one really had a full grasp of the person he was becoming.
“As a teenager, his sensory condition made him exceedingly sensitive to textures, sound, light, and movement. He shunned his classmates, bothered by their choice of clothes and the noises they made. He cultivated a set of ground rules that fed his separateness,” write reporters Josh Kovner and Dave Altimari. The critical addition to this toxic brew was an absence of empathy and social compassion, according to Harold I. Schwartz, MD, a psychiatrist and former member of the Sandy Hook Advisory Commission, which studied the shootings.
“In this mental state, known as solipsism, only the solipsist is real. Everyone else in the world is a cardboard cutout, placed there for your benefit and otherwise devoid of meaning or value. It is the most extreme end of one form of malignant narcissism. If the victims have no value, then there is nothing to constrain you from shooting them,” Dr. Schwartz says.
In a note accompanying the article, the editors write: “Understanding what a mass killer was thinking not only paints a clearer picture of the individual, it helps us identify and understand red flags that could be part of a prevention formula for future mass shootings.”
Five years after the legalization of marijuana in Colorado, anticipated legislation in 2019 could see home delivery of cannabis and cannabis-related products, and expanded medical availability.
Governor-elect Jared Polis, who takes office in the new year, probably will take a different approach from outgoing Gov. John Hickenlooper, according to a recent article in the Denver Post. Mr. Hickenlooper vetoed previous legislation intended to increase drug’s accessibility.
“ says Albert Gutierrez, CEO of MedPharm Holdings, a cannabis research and cultivation company.
“You’re going to probably have more variety from these companies, whether they’re offering drinks or chocolate bars. But these companies are going to be the household names that people are going to come to know over the next 30, 50, 100 years,” he says.
Not everyone is on board. “We should all be able to agree that Colorado’s increasingly potent marijuana products are harmful to youth and that we have a collective responsibility to protect Colorado kids,” writes Henny Lasley, the cofounder of Smart Colorado, which was formed in opposition to the legalization of marijuana in the state.
The availability of medical marijuana for people diagnosed with autism spectrum disorders is among the vetoed initiatives that are likely to reemerge in 2019. That bill reportedly was opposed by the Colorado Child and Adolescent Psychiatric Society, the Colorado Psychiatric Society, and by Larry Wolk, MD, who recently stepped down as chief medical officer of the state’s department of public health and environment.
Adjusting to life after fires
The latest wildfires have been vanquished in California. For those affected recently and in the past several years has come the reality that the draw of living on the edge of nature means living surrounded by tinder-dry terrain. It’s a great location – until it ignites.
A year ago, the Thomas Fire devastated Ventura and Santa Barbara counties, burning more than 440 square miles. Few people died, but more than 1,000 buildings were destroyed – and hundreds of people were left homeless. A year later, in the Clearpoint neighborhood of Ventura, residential lots sit empty, their owners having abandoned the effort to rebuild. Others, like Sandra and Ed Fuller, are choosing to begin again. The beauty of the area that pulled them there years ago remains strong.
They have come to terms with losing their home to the fire. “I think it was a sort of a breaking point where there was just a flood of peace that kind of went through. It’s like there is nothing we can do about this. We know what we have to do now. We’ll just get on with it,” Ed Fuller says in an interview with NPR.
Having the Christmas season looming has been a boost to their spirits and planning. “My wife is absolutely obsessed that she’s ready for Christmas. Last Christmas we sort of lost.”
The invisibility of asexuality
It can be hard for some to fathom that sex just isn’t important for some. “They are the friends and family members who don’t express any desire to pursue sexual intimacy, who don’t often or ever seem interested in conventional dating, and who get pushed to the sidelines in any conversation about sexual health,” Kate Sloan writes in a recent article in the Walrus.
“Much like same-sex attraction decades ago, this nonattraction was initially (and is sometimes still) conflated with a sexual-desire disorder, worthy of pathologization and medical treatment with pharmaceuticals or therapy. But scientists have confirmed asexuality isn’t a medical issue; it is a sexual orientation on the same plane as heterosexuality, homosexuality, and bisexuality,” Ms. Sloan writes.
“If someone is gay, as an example, it’s pretty easy to say, ‘Okay, well, I experience the same type of attraction that everyone else does, it’s just pointed at a different gender,’ ” says Brian Langevin, executive director of the nonprofit organization Asexual Outreach. “For asexual people ... they might not even know that sexual attraction exists, and to them, the whole world could seem very confusing.”
Meanwhile, a 2013 study in British Columbia showed that asexual individuals are more likely to be socially isolated, depressed, and anxious.
“True emotional intimacy is created, according to psychology, by honesty, empathy, and listening,” Ms. Sloan writes. “When we oversimplify relationships by insisting, on a sociocultural level, that sex is the ultimate key to and only sign of a profound connection, we deprive ourselves of the more holistic affinities available to us if we look for more.”
Fundamental churches face allegations
Joy Evans Ryder was 15 when she reportedly was raped by Dave Hyles, youth director at her Baptist church in Hammond, Ind. She was not the youth director’s only alleged victim. He never faced charges; in a scenario strikingly similar to that of hundreds of Roman Catholic priests, he escaped local prosecution by being moved on to other assignments.
An investigation by the Fort Worth (Tex.) Star-Telegram has unearthed a decades-old cover-up of more than 400 cases of sexual abuse at independent fundamental Baptist churches across the United States.
Former members of congregations point to the cultlike power of many independent fundamental Baptist churches and the constant pressure to never question pastors or leave the church.
“We didn’t have a compound ... but it may as well have been. Our mind was the compound,” says a former member. Some of the abused believed that if they disobeyed the pastor or left the church, God would kill them or their family.
Some independent fundamental Baptist churches preach separation from the world, nonbelievers, and Christians with other religious views. A natural outcome, according to Josh Elliott, a former member of Vineyard’s Oklahoma City church, is that for any issues, “even legal issues, you go to the pastor first, not the police. ... You don’t report to police because the pastor is the ultimate authority, not the government.”
“I see a culture where pastoral authority is taken to a level that’s beyond what the Scripture teaches,” says Tim Heck, who was a deacon at Faith Baptist Church in Wildomar, Calif., and whose daughter said she had been abused by the youth pastor there. “I think the independent fundamental Baptists have lost their way.”
Adam Lanza’s ‘separateness’ exposed
Written musings and other documents by Adam Lanza – who slaughtered 20 first-graders and six teachers at Sandy Hook Elementary School in Newtown, Conn., on Dec. 14, 2012 – have been reported by the Hartford Courant.
Adam Lanza was challenged by speech and sensory issues as a child but had a keen intellect. That potential was eclipsed in his teenage years by paranoia, disdain for relationships, and contempt for others, the documents show. Family, teachers, and counselors were aware of his isolation. And, with time, his obsessions and mental/physical deterioration grew. But the documents make clear that no one really had a full grasp of the person he was becoming.
“As a teenager, his sensory condition made him exceedingly sensitive to textures, sound, light, and movement. He shunned his classmates, bothered by their choice of clothes and the noises they made. He cultivated a set of ground rules that fed his separateness,” write reporters Josh Kovner and Dave Altimari. The critical addition to this toxic brew was an absence of empathy and social compassion, according to Harold I. Schwartz, MD, a psychiatrist and former member of the Sandy Hook Advisory Commission, which studied the shootings.
“In this mental state, known as solipsism, only the solipsist is real. Everyone else in the world is a cardboard cutout, placed there for your benefit and otherwise devoid of meaning or value. It is the most extreme end of one form of malignant narcissism. If the victims have no value, then there is nothing to constrain you from shooting them,” Dr. Schwartz says.
In a note accompanying the article, the editors write: “Understanding what a mass killer was thinking not only paints a clearer picture of the individual, it helps us identify and understand red flags that could be part of a prevention formula for future mass shootings.”
Five years after the legalization of marijuana in Colorado, anticipated legislation in 2019 could see home delivery of cannabis and cannabis-related products, and expanded medical availability.
Governor-elect Jared Polis, who takes office in the new year, probably will take a different approach from outgoing Gov. John Hickenlooper, according to a recent article in the Denver Post. Mr. Hickenlooper vetoed previous legislation intended to increase drug’s accessibility.
“ says Albert Gutierrez, CEO of MedPharm Holdings, a cannabis research and cultivation company.
“You’re going to probably have more variety from these companies, whether they’re offering drinks or chocolate bars. But these companies are going to be the household names that people are going to come to know over the next 30, 50, 100 years,” he says.
Not everyone is on board. “We should all be able to agree that Colorado’s increasingly potent marijuana products are harmful to youth and that we have a collective responsibility to protect Colorado kids,” writes Henny Lasley, the cofounder of Smart Colorado, which was formed in opposition to the legalization of marijuana in the state.
The availability of medical marijuana for people diagnosed with autism spectrum disorders is among the vetoed initiatives that are likely to reemerge in 2019. That bill reportedly was opposed by the Colorado Child and Adolescent Psychiatric Society, the Colorado Psychiatric Society, and by Larry Wolk, MD, who recently stepped down as chief medical officer of the state’s department of public health and environment.
Adjusting to life after fires
The latest wildfires have been vanquished in California. For those affected recently and in the past several years has come the reality that the draw of living on the edge of nature means living surrounded by tinder-dry terrain. It’s a great location – until it ignites.
A year ago, the Thomas Fire devastated Ventura and Santa Barbara counties, burning more than 440 square miles. Few people died, but more than 1,000 buildings were destroyed – and hundreds of people were left homeless. A year later, in the Clearpoint neighborhood of Ventura, residential lots sit empty, their owners having abandoned the effort to rebuild. Others, like Sandra and Ed Fuller, are choosing to begin again. The beauty of the area that pulled them there years ago remains strong.
They have come to terms with losing their home to the fire. “I think it was a sort of a breaking point where there was just a flood of peace that kind of went through. It’s like there is nothing we can do about this. We know what we have to do now. We’ll just get on with it,” Ed Fuller says in an interview with NPR.
Having the Christmas season looming has been a boost to their spirits and planning. “My wife is absolutely obsessed that she’s ready for Christmas. Last Christmas we sort of lost.”
The invisibility of asexuality
It can be hard for some to fathom that sex just isn’t important for some. “They are the friends and family members who don’t express any desire to pursue sexual intimacy, who don’t often or ever seem interested in conventional dating, and who get pushed to the sidelines in any conversation about sexual health,” Kate Sloan writes in a recent article in the Walrus.
“Much like same-sex attraction decades ago, this nonattraction was initially (and is sometimes still) conflated with a sexual-desire disorder, worthy of pathologization and medical treatment with pharmaceuticals or therapy. But scientists have confirmed asexuality isn’t a medical issue; it is a sexual orientation on the same plane as heterosexuality, homosexuality, and bisexuality,” Ms. Sloan writes.
“If someone is gay, as an example, it’s pretty easy to say, ‘Okay, well, I experience the same type of attraction that everyone else does, it’s just pointed at a different gender,’ ” says Brian Langevin, executive director of the nonprofit organization Asexual Outreach. “For asexual people ... they might not even know that sexual attraction exists, and to them, the whole world could seem very confusing.”
Meanwhile, a 2013 study in British Columbia showed that asexual individuals are more likely to be socially isolated, depressed, and anxious.
“True emotional intimacy is created, according to psychology, by honesty, empathy, and listening,” Ms. Sloan writes. “When we oversimplify relationships by insisting, on a sociocultural level, that sex is the ultimate key to and only sign of a profound connection, we deprive ourselves of the more holistic affinities available to us if we look for more.”
Fundamental churches face allegations
Joy Evans Ryder was 15 when she reportedly was raped by Dave Hyles, youth director at her Baptist church in Hammond, Ind. She was not the youth director’s only alleged victim. He never faced charges; in a scenario strikingly similar to that of hundreds of Roman Catholic priests, he escaped local prosecution by being moved on to other assignments.
An investigation by the Fort Worth (Tex.) Star-Telegram has unearthed a decades-old cover-up of more than 400 cases of sexual abuse at independent fundamental Baptist churches across the United States.
Former members of congregations point to the cultlike power of many independent fundamental Baptist churches and the constant pressure to never question pastors or leave the church.
“We didn’t have a compound ... but it may as well have been. Our mind was the compound,” says a former member. Some of the abused believed that if they disobeyed the pastor or left the church, God would kill them or their family.
Some independent fundamental Baptist churches preach separation from the world, nonbelievers, and Christians with other religious views. A natural outcome, according to Josh Elliott, a former member of Vineyard’s Oklahoma City church, is that for any issues, “even legal issues, you go to the pastor first, not the police. ... You don’t report to police because the pastor is the ultimate authority, not the government.”
“I see a culture where pastoral authority is taken to a level that’s beyond what the Scripture teaches,” says Tim Heck, who was a deacon at Faith Baptist Church in Wildomar, Calif., and whose daughter said she had been abused by the youth pastor there. “I think the independent fundamental Baptists have lost their way.”
Adam Lanza’s ‘separateness’ exposed
Written musings and other documents by Adam Lanza – who slaughtered 20 first-graders and six teachers at Sandy Hook Elementary School in Newtown, Conn., on Dec. 14, 2012 – have been reported by the Hartford Courant.
Adam Lanza was challenged by speech and sensory issues as a child but had a keen intellect. That potential was eclipsed in his teenage years by paranoia, disdain for relationships, and contempt for others, the documents show. Family, teachers, and counselors were aware of his isolation. And, with time, his obsessions and mental/physical deterioration grew. But the documents make clear that no one really had a full grasp of the person he was becoming.
“As a teenager, his sensory condition made him exceedingly sensitive to textures, sound, light, and movement. He shunned his classmates, bothered by their choice of clothes and the noises they made. He cultivated a set of ground rules that fed his separateness,” write reporters Josh Kovner and Dave Altimari. The critical addition to this toxic brew was an absence of empathy and social compassion, according to Harold I. Schwartz, MD, a psychiatrist and former member of the Sandy Hook Advisory Commission, which studied the shootings.
“In this mental state, known as solipsism, only the solipsist is real. Everyone else in the world is a cardboard cutout, placed there for your benefit and otherwise devoid of meaning or value. It is the most extreme end of one form of malignant narcissism. If the victims have no value, then there is nothing to constrain you from shooting them,” Dr. Schwartz says.
In a note accompanying the article, the editors write: “Understanding what a mass killer was thinking not only paints a clearer picture of the individual, it helps us identify and understand red flags that could be part of a prevention formula for future mass shootings.”
New PTSD prevention guidelines released
Hydrocortisone is only drug rated as an ‘intervention with emerging evidence of efficacy’
Barcelona – New evidence-based guidelines on posttraumatic stress disorder prevention and treatment from the International Society for Traumatic Stress Studies (ISTSS) highlight an uncomfortable truth: Namely, the basis for early formal intervention of any sort is sorely lacking.
“I’m acutely aware that a lot of people in the mental health field are not aware of the evidence base as it stands at the moment,” Jonathan I. Bisson, MD, said at the annual congress of the European College of Neuropsychopharmacology. “There’s something very human about trying to do something. I think we find it very hard to do nothing following a traumatic event.”
Dr. Bisson, a professor of psychiatry at Cardiff (Wales) University and the chair of the ISTSS guidelines committee, provided an advance look at the ISTSS guidelines, which have since been released.
Secondary prevention of PTSD can entail either blocking development of symptoms after exposure to trauma or treating early emergent PTSD symptoms. Dr. Bisson emphasized that, although multiple exciting prospects are on the horizon for secondary prevention, those interventions need further work before implementation. The ISTSS guidelines, based on the group’s meta-analyses of 361 randomized controlled trials, rated most of the diverse psychosocial, psychological, and pharmacologic interventions that have been proposed or are now actually being used in clinical practice as either “low effect,” “interventions with emerging evidence,” or “insufficient evidence to recommend.” Those interventions are not backed by sufficient evidence of efficacy to be ready for prime time use in clinical practice.
Morever, the potential for iatrogenic harm is very real.
to a trauma,” the psychiatrist observed. “It’s normal to cry after a bereavement, for example. But should we be pathologizing that, or is that the body’s way of actually bringing itself to terms with something that’s very extreme?
“So we’ve got to be careful in our efforts to shape emotional processing, which might do absolutely nothing – which I’d argue is a problem when we’ve got limited resources because we should be focusing those resources on things that make a difference. Or it could minimize or prevent prolonged distress or pathology, which is what we’re after. Or it could interfere with the adaptive acute stress response – and that’s a real problem and one we’ve got to be very careful about,” Dr. Bisson said. “So ‘primum non nocere’ – first do no harm – should be a principle we adhere to.”
Neurobiology of PTSD
The accepted view of the neurobiology of PTSD is that it represents a failure of the medial prefrontal/anterior cingulate network to regulate activity in the amygdala, with resultant hyperreactivity to threat. Enhanced negative feedback of cortisol occurs. The brain’s response to low cortisol is to increase levels of corticotropin-releasing factor, which has the unwanted consequence of increased locus coeruleus activity and noradrenaline release. The resultant adrenergic surge facilitates the laying down and consolidation of traumatic memories.
Also, low cortisol levels disinhibit retrieval of traumatic memories, so the affected individual thinks more about the trauma. All of this elicits an uncontrolled sympathetic response, so the patient remains in a constant state of hyperarousal characteristic of PTSD.
“In theory we should have some really simple ways to prevent PTSD from occurring if we get in there soon enough: reducing noradrenergic overactivity via alpha2-adrenergic receptor agonism with an agent such as clonidine; postsynaptic beta-adrenergic blocking with a drug such as propranolol; or alpha1-adrenergic receptor blocking, as with prazosin. All of these approaches reduce noradrenergic tone and therefore should be effective, in theory, to prevent PTSD.
“We should also be able to use indirect strategies to reduce noradrenergic overactivity: GABA agents like benzodiazepines, alcohol, and gabapentin oppose noradrenaline action in the amygdala. I’m not suggesting drinking all the time to prevent PTSD, but there’s a strong association in several studies, with about a 50% reduction in rates of PTSD in those who are intoxicated at the time of the trauma,” according to Dr. Bisson.
Unfortunately, to date, none of those pharmacologic approaches have been effective when studied in randomized trials.
One pharmacologic intervention
Only one drug, hydrocortisone, was rated an “intervention with emerging evidence of efficacy” for prevention of PTSD symptoms in adults when given within the first 3 months after a traumatic event. Three placebo-controlled, randomized trials have shown a positive effect.
“It should be said that most of the studies of hydrocortisone have been done in individuals following extreme physical illness, such as septic shock sufferers, so the generalizability is a bit of a question. Nevertheless, it’s the one agent that has meta-analytic evidence of being effective at preventing PTSD, although more research is needed,” Dr. Bisson said.
Results of randomized trials featuring those agents have been “really disappointing” in light of what seems a sound theoretic rationale, he continued.
“We’re really struggling from a pharmacologic perspective to know what to do. I would say we are still at the experimental stage, and there’s no real good evidence that we should give any medication to prevent PTSD,” Dr. Bisson said.
Early psychosocial interventions
The ISTSS guidelines rate only two single-session interventions for prevention as rising to the promising level of “emerging evidence” of clinically important benefit: single-session eye movement desensitization and reprocessing (EMDR), which in its multisession format is a well-established treatment with strong evidence of efficacy in established PTSD, and a program known as Group 512 PM, which combines group debriefing with group cohesion–building exercises.
“Group 512 PM was done in groups of Chinese army personnel helping in recovery efforts following a 2008 earthquake in China that killed 80,000 people. It resulted in nearly a 50% reduction in PTSD versus no debriefing. This cohesion training might be a clue to us as something to work on in the future,” Dr. Bisson said.
The ISTSS guidelines deem there is insufficient evidence to recommend single-session group debriefing, group stress management, heart stress management, group education, trauma-focused counselling, computerized visuospatial task, individual psychoeducation, or individual debriefing.
“In six randomized controlled trials over nearly the last 20 years, we see a strong signal that individual psychological debriefing isn’t effective. So, certainly, going into a room with an individual or a couple and talking about what they’ve been through in great detail and getting them to express their emotions and advising them that’s a normal reaction doesn’t seem to be enough. And rather worryingly, the people who tend to do worse with that sort of intervention are the people who’ve got the most symptoms when they started, so they’re the ones at highest risk of developing PTSD,” Dr. Bisson said.
Multisession prevention interventions such as brief dyadic therapy and self-guided Internet interventions are supported by emerging evidence. Less promising, and with insufficient evidence to recommend, according to the ISTSS, are brief interpersonal therapy, brief individual trauma processing therapy, telephone-based cognitive-behavioral therapy (CBT), and nurse-led intensive care recovery programs.
For multisession early treatment interventions for patients with emerging traumatic stress symptoms within the first 3 months, the new ISTSS guidelines recommend as standard therapy CBT with a trauma focus, EMDR, or cognitive therapy. Stepped or collaborative care is rated as having “low effect.” There is emerging evidence for structured writing interventions and Internet-based guided self-help. And there is insufficient evidence to recommend behavioral activation, Internet virtual reality therapy, telephone-based CBT with a trauma focus, computerized neurobehavioral training, or supportive counseling.
Treating adults with established PTSD
Pharmacotherapy, including fluoxetine, sertraline, paroxetine, and venlafaxine is rated in the guidelines as a low-effect treatment. Quetiapine has emerging evidence of efficacy. Everything else has insufficient evidence.
Psychological therapies such as EMDR, CBT with a trauma focus, prolonged exposure, cognitive therapy, and cognitive processing therapy received strong recommendations. In fact, those are the only interventions in the entire ISTSS guidelines that received a “strong recommendation” rating. A weaker “standard recommendation” is given to CBT without a trauma focus, narrative exposure therapy, present-centered therapy, group CBT with a trauma focus, and guided Internet-based therapy with a trauma focus. Interventions with emerging evidence of efficacy include virtual reality therapy, reconsolidation of traumatic memories, and couples CBT with a trauma focus.
Best-practice approach to prevention
“In my view, and what I tell people, is that after a traumatic event I think practical pragmatic support in an empathic manner is the best first step,” Dr. Bisson said. “And it doesn’t have to be provided by a mental health professional. In fact, your family and friends are the best people to provide that. And then, we watchfully wait to see if traumatic stress symptoms emerge. If they do, and particularly if their trajectory is going up, then at about 1 month, I would get in there and deliver a therapy, either CBT with a trauma focus, EMDR, or cognitive therapy with a trauma focus. All of those have a significant positive effect for this group.”
Although he restricted his talk to secondary prevention of PTSD in adults, the ISTSS guidelines also address early intervention in children and adolescents.
Dr. Bisson reported having no financial conflicts of interest regarding his presentation.
Hydrocortisone is only drug rated as an ‘intervention with emerging evidence of efficacy’
Hydrocortisone is only drug rated as an ‘intervention with emerging evidence of efficacy’
Barcelona – New evidence-based guidelines on posttraumatic stress disorder prevention and treatment from the International Society for Traumatic Stress Studies (ISTSS) highlight an uncomfortable truth: Namely, the basis for early formal intervention of any sort is sorely lacking.
“I’m acutely aware that a lot of people in the mental health field are not aware of the evidence base as it stands at the moment,” Jonathan I. Bisson, MD, said at the annual congress of the European College of Neuropsychopharmacology. “There’s something very human about trying to do something. I think we find it very hard to do nothing following a traumatic event.”
Dr. Bisson, a professor of psychiatry at Cardiff (Wales) University and the chair of the ISTSS guidelines committee, provided an advance look at the ISTSS guidelines, which have since been released.
Secondary prevention of PTSD can entail either blocking development of symptoms after exposure to trauma or treating early emergent PTSD symptoms. Dr. Bisson emphasized that, although multiple exciting prospects are on the horizon for secondary prevention, those interventions need further work before implementation. The ISTSS guidelines, based on the group’s meta-analyses of 361 randomized controlled trials, rated most of the diverse psychosocial, psychological, and pharmacologic interventions that have been proposed or are now actually being used in clinical practice as either “low effect,” “interventions with emerging evidence,” or “insufficient evidence to recommend.” Those interventions are not backed by sufficient evidence of efficacy to be ready for prime time use in clinical practice.
Morever, the potential for iatrogenic harm is very real.
to a trauma,” the psychiatrist observed. “It’s normal to cry after a bereavement, for example. But should we be pathologizing that, or is that the body’s way of actually bringing itself to terms with something that’s very extreme?
“So we’ve got to be careful in our efforts to shape emotional processing, which might do absolutely nothing – which I’d argue is a problem when we’ve got limited resources because we should be focusing those resources on things that make a difference. Or it could minimize or prevent prolonged distress or pathology, which is what we’re after. Or it could interfere with the adaptive acute stress response – and that’s a real problem and one we’ve got to be very careful about,” Dr. Bisson said. “So ‘primum non nocere’ – first do no harm – should be a principle we adhere to.”
Neurobiology of PTSD
The accepted view of the neurobiology of PTSD is that it represents a failure of the medial prefrontal/anterior cingulate network to regulate activity in the amygdala, with resultant hyperreactivity to threat. Enhanced negative feedback of cortisol occurs. The brain’s response to low cortisol is to increase levels of corticotropin-releasing factor, which has the unwanted consequence of increased locus coeruleus activity and noradrenaline release. The resultant adrenergic surge facilitates the laying down and consolidation of traumatic memories.
Also, low cortisol levels disinhibit retrieval of traumatic memories, so the affected individual thinks more about the trauma. All of this elicits an uncontrolled sympathetic response, so the patient remains in a constant state of hyperarousal characteristic of PTSD.
“In theory we should have some really simple ways to prevent PTSD from occurring if we get in there soon enough: reducing noradrenergic overactivity via alpha2-adrenergic receptor agonism with an agent such as clonidine; postsynaptic beta-adrenergic blocking with a drug such as propranolol; or alpha1-adrenergic receptor blocking, as with prazosin. All of these approaches reduce noradrenergic tone and therefore should be effective, in theory, to prevent PTSD.
“We should also be able to use indirect strategies to reduce noradrenergic overactivity: GABA agents like benzodiazepines, alcohol, and gabapentin oppose noradrenaline action in the amygdala. I’m not suggesting drinking all the time to prevent PTSD, but there’s a strong association in several studies, with about a 50% reduction in rates of PTSD in those who are intoxicated at the time of the trauma,” according to Dr. Bisson.
Unfortunately, to date, none of those pharmacologic approaches have been effective when studied in randomized trials.
One pharmacologic intervention
Only one drug, hydrocortisone, was rated an “intervention with emerging evidence of efficacy” for prevention of PTSD symptoms in adults when given within the first 3 months after a traumatic event. Three placebo-controlled, randomized trials have shown a positive effect.
“It should be said that most of the studies of hydrocortisone have been done in individuals following extreme physical illness, such as septic shock sufferers, so the generalizability is a bit of a question. Nevertheless, it’s the one agent that has meta-analytic evidence of being effective at preventing PTSD, although more research is needed,” Dr. Bisson said.
Results of randomized trials featuring those agents have been “really disappointing” in light of what seems a sound theoretic rationale, he continued.
“We’re really struggling from a pharmacologic perspective to know what to do. I would say we are still at the experimental stage, and there’s no real good evidence that we should give any medication to prevent PTSD,” Dr. Bisson said.
Early psychosocial interventions
The ISTSS guidelines rate only two single-session interventions for prevention as rising to the promising level of “emerging evidence” of clinically important benefit: single-session eye movement desensitization and reprocessing (EMDR), which in its multisession format is a well-established treatment with strong evidence of efficacy in established PTSD, and a program known as Group 512 PM, which combines group debriefing with group cohesion–building exercises.
“Group 512 PM was done in groups of Chinese army personnel helping in recovery efforts following a 2008 earthquake in China that killed 80,000 people. It resulted in nearly a 50% reduction in PTSD versus no debriefing. This cohesion training might be a clue to us as something to work on in the future,” Dr. Bisson said.
The ISTSS guidelines deem there is insufficient evidence to recommend single-session group debriefing, group stress management, heart stress management, group education, trauma-focused counselling, computerized visuospatial task, individual psychoeducation, or individual debriefing.
“In six randomized controlled trials over nearly the last 20 years, we see a strong signal that individual psychological debriefing isn’t effective. So, certainly, going into a room with an individual or a couple and talking about what they’ve been through in great detail and getting them to express their emotions and advising them that’s a normal reaction doesn’t seem to be enough. And rather worryingly, the people who tend to do worse with that sort of intervention are the people who’ve got the most symptoms when they started, so they’re the ones at highest risk of developing PTSD,” Dr. Bisson said.
Multisession prevention interventions such as brief dyadic therapy and self-guided Internet interventions are supported by emerging evidence. Less promising, and with insufficient evidence to recommend, according to the ISTSS, are brief interpersonal therapy, brief individual trauma processing therapy, telephone-based cognitive-behavioral therapy (CBT), and nurse-led intensive care recovery programs.
For multisession early treatment interventions for patients with emerging traumatic stress symptoms within the first 3 months, the new ISTSS guidelines recommend as standard therapy CBT with a trauma focus, EMDR, or cognitive therapy. Stepped or collaborative care is rated as having “low effect.” There is emerging evidence for structured writing interventions and Internet-based guided self-help. And there is insufficient evidence to recommend behavioral activation, Internet virtual reality therapy, telephone-based CBT with a trauma focus, computerized neurobehavioral training, or supportive counseling.
Treating adults with established PTSD
Pharmacotherapy, including fluoxetine, sertraline, paroxetine, and venlafaxine is rated in the guidelines as a low-effect treatment. Quetiapine has emerging evidence of efficacy. Everything else has insufficient evidence.
Psychological therapies such as EMDR, CBT with a trauma focus, prolonged exposure, cognitive therapy, and cognitive processing therapy received strong recommendations. In fact, those are the only interventions in the entire ISTSS guidelines that received a “strong recommendation” rating. A weaker “standard recommendation” is given to CBT without a trauma focus, narrative exposure therapy, present-centered therapy, group CBT with a trauma focus, and guided Internet-based therapy with a trauma focus. Interventions with emerging evidence of efficacy include virtual reality therapy, reconsolidation of traumatic memories, and couples CBT with a trauma focus.
Best-practice approach to prevention
“In my view, and what I tell people, is that after a traumatic event I think practical pragmatic support in an empathic manner is the best first step,” Dr. Bisson said. “And it doesn’t have to be provided by a mental health professional. In fact, your family and friends are the best people to provide that. And then, we watchfully wait to see if traumatic stress symptoms emerge. If they do, and particularly if their trajectory is going up, then at about 1 month, I would get in there and deliver a therapy, either CBT with a trauma focus, EMDR, or cognitive therapy with a trauma focus. All of those have a significant positive effect for this group.”
Although he restricted his talk to secondary prevention of PTSD in adults, the ISTSS guidelines also address early intervention in children and adolescents.
Dr. Bisson reported having no financial conflicts of interest regarding his presentation.
Barcelona – New evidence-based guidelines on posttraumatic stress disorder prevention and treatment from the International Society for Traumatic Stress Studies (ISTSS) highlight an uncomfortable truth: Namely, the basis for early formal intervention of any sort is sorely lacking.
“I’m acutely aware that a lot of people in the mental health field are not aware of the evidence base as it stands at the moment,” Jonathan I. Bisson, MD, said at the annual congress of the European College of Neuropsychopharmacology. “There’s something very human about trying to do something. I think we find it very hard to do nothing following a traumatic event.”
Dr. Bisson, a professor of psychiatry at Cardiff (Wales) University and the chair of the ISTSS guidelines committee, provided an advance look at the ISTSS guidelines, which have since been released.
Secondary prevention of PTSD can entail either blocking development of symptoms after exposure to trauma or treating early emergent PTSD symptoms. Dr. Bisson emphasized that, although multiple exciting prospects are on the horizon for secondary prevention, those interventions need further work before implementation. The ISTSS guidelines, based on the group’s meta-analyses of 361 randomized controlled trials, rated most of the diverse psychosocial, psychological, and pharmacologic interventions that have been proposed or are now actually being used in clinical practice as either “low effect,” “interventions with emerging evidence,” or “insufficient evidence to recommend.” Those interventions are not backed by sufficient evidence of efficacy to be ready for prime time use in clinical practice.
Morever, the potential for iatrogenic harm is very real.
to a trauma,” the psychiatrist observed. “It’s normal to cry after a bereavement, for example. But should we be pathologizing that, or is that the body’s way of actually bringing itself to terms with something that’s very extreme?
“So we’ve got to be careful in our efforts to shape emotional processing, which might do absolutely nothing – which I’d argue is a problem when we’ve got limited resources because we should be focusing those resources on things that make a difference. Or it could minimize or prevent prolonged distress or pathology, which is what we’re after. Or it could interfere with the adaptive acute stress response – and that’s a real problem and one we’ve got to be very careful about,” Dr. Bisson said. “So ‘primum non nocere’ – first do no harm – should be a principle we adhere to.”
Neurobiology of PTSD
The accepted view of the neurobiology of PTSD is that it represents a failure of the medial prefrontal/anterior cingulate network to regulate activity in the amygdala, with resultant hyperreactivity to threat. Enhanced negative feedback of cortisol occurs. The brain’s response to low cortisol is to increase levels of corticotropin-releasing factor, which has the unwanted consequence of increased locus coeruleus activity and noradrenaline release. The resultant adrenergic surge facilitates the laying down and consolidation of traumatic memories.
Also, low cortisol levels disinhibit retrieval of traumatic memories, so the affected individual thinks more about the trauma. All of this elicits an uncontrolled sympathetic response, so the patient remains in a constant state of hyperarousal characteristic of PTSD.
“In theory we should have some really simple ways to prevent PTSD from occurring if we get in there soon enough: reducing noradrenergic overactivity via alpha2-adrenergic receptor agonism with an agent such as clonidine; postsynaptic beta-adrenergic blocking with a drug such as propranolol; or alpha1-adrenergic receptor blocking, as with prazosin. All of these approaches reduce noradrenergic tone and therefore should be effective, in theory, to prevent PTSD.
“We should also be able to use indirect strategies to reduce noradrenergic overactivity: GABA agents like benzodiazepines, alcohol, and gabapentin oppose noradrenaline action in the amygdala. I’m not suggesting drinking all the time to prevent PTSD, but there’s a strong association in several studies, with about a 50% reduction in rates of PTSD in those who are intoxicated at the time of the trauma,” according to Dr. Bisson.
Unfortunately, to date, none of those pharmacologic approaches have been effective when studied in randomized trials.
One pharmacologic intervention
Only one drug, hydrocortisone, was rated an “intervention with emerging evidence of efficacy” for prevention of PTSD symptoms in adults when given within the first 3 months after a traumatic event. Three placebo-controlled, randomized trials have shown a positive effect.
“It should be said that most of the studies of hydrocortisone have been done in individuals following extreme physical illness, such as septic shock sufferers, so the generalizability is a bit of a question. Nevertheless, it’s the one agent that has meta-analytic evidence of being effective at preventing PTSD, although more research is needed,” Dr. Bisson said.
Results of randomized trials featuring those agents have been “really disappointing” in light of what seems a sound theoretic rationale, he continued.
“We’re really struggling from a pharmacologic perspective to know what to do. I would say we are still at the experimental stage, and there’s no real good evidence that we should give any medication to prevent PTSD,” Dr. Bisson said.
Early psychosocial interventions
The ISTSS guidelines rate only two single-session interventions for prevention as rising to the promising level of “emerging evidence” of clinically important benefit: single-session eye movement desensitization and reprocessing (EMDR), which in its multisession format is a well-established treatment with strong evidence of efficacy in established PTSD, and a program known as Group 512 PM, which combines group debriefing with group cohesion–building exercises.
“Group 512 PM was done in groups of Chinese army personnel helping in recovery efforts following a 2008 earthquake in China that killed 80,000 people. It resulted in nearly a 50% reduction in PTSD versus no debriefing. This cohesion training might be a clue to us as something to work on in the future,” Dr. Bisson said.
The ISTSS guidelines deem there is insufficient evidence to recommend single-session group debriefing, group stress management, heart stress management, group education, trauma-focused counselling, computerized visuospatial task, individual psychoeducation, or individual debriefing.
“In six randomized controlled trials over nearly the last 20 years, we see a strong signal that individual psychological debriefing isn’t effective. So, certainly, going into a room with an individual or a couple and talking about what they’ve been through in great detail and getting them to express their emotions and advising them that’s a normal reaction doesn’t seem to be enough. And rather worryingly, the people who tend to do worse with that sort of intervention are the people who’ve got the most symptoms when they started, so they’re the ones at highest risk of developing PTSD,” Dr. Bisson said.
Multisession prevention interventions such as brief dyadic therapy and self-guided Internet interventions are supported by emerging evidence. Less promising, and with insufficient evidence to recommend, according to the ISTSS, are brief interpersonal therapy, brief individual trauma processing therapy, telephone-based cognitive-behavioral therapy (CBT), and nurse-led intensive care recovery programs.
For multisession early treatment interventions for patients with emerging traumatic stress symptoms within the first 3 months, the new ISTSS guidelines recommend as standard therapy CBT with a trauma focus, EMDR, or cognitive therapy. Stepped or collaborative care is rated as having “low effect.” There is emerging evidence for structured writing interventions and Internet-based guided self-help. And there is insufficient evidence to recommend behavioral activation, Internet virtual reality therapy, telephone-based CBT with a trauma focus, computerized neurobehavioral training, or supportive counseling.
Treating adults with established PTSD
Pharmacotherapy, including fluoxetine, sertraline, paroxetine, and venlafaxine is rated in the guidelines as a low-effect treatment. Quetiapine has emerging evidence of efficacy. Everything else has insufficient evidence.
Psychological therapies such as EMDR, CBT with a trauma focus, prolonged exposure, cognitive therapy, and cognitive processing therapy received strong recommendations. In fact, those are the only interventions in the entire ISTSS guidelines that received a “strong recommendation” rating. A weaker “standard recommendation” is given to CBT without a trauma focus, narrative exposure therapy, present-centered therapy, group CBT with a trauma focus, and guided Internet-based therapy with a trauma focus. Interventions with emerging evidence of efficacy include virtual reality therapy, reconsolidation of traumatic memories, and couples CBT with a trauma focus.
Best-practice approach to prevention
“In my view, and what I tell people, is that after a traumatic event I think practical pragmatic support in an empathic manner is the best first step,” Dr. Bisson said. “And it doesn’t have to be provided by a mental health professional. In fact, your family and friends are the best people to provide that. And then, we watchfully wait to see if traumatic stress symptoms emerge. If they do, and particularly if their trajectory is going up, then at about 1 month, I would get in there and deliver a therapy, either CBT with a trauma focus, EMDR, or cognitive therapy with a trauma focus. All of those have a significant positive effect for this group.”
Although he restricted his talk to secondary prevention of PTSD in adults, the ISTSS guidelines also address early intervention in children and adolescents.
Dr. Bisson reported having no financial conflicts of interest regarding his presentation.
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Overemphasizing Communities in the National Strategy for Preventing Veteran Suicide Could Undercut VA Successes
In June 2018, the US Department of Veterans Affairs (VA) issued its National Strategy for Preventing Veteran Suicide, 2018-2028. Its 14 goals—many highly innovative—are “to provide a framework for identifying priorities, organizing efforts, and contributing to a national focus on Veteran suicide prevention.”1
The National Strategy recognizes that suicide prevention requires a 3-pronged approach that includes universal, selective, and targeted strategies because “suicide cannot be prevented by any single strategy.”1 Even so, the National Strategy does not heed this core tenet. It focuses exclusively on universal, non-VA community-based priorities and efforts. That focus causes a problem because it neglects the other strategies. It also is precarious because in the current era of VA zero sum budgets, increases in 1 domain come from decreases in another. Thus, sole prioritizing of universal community components could divert funds from extant effective VA suicide prevention programs.
Community-based engagement is unquestionably necessary to prevent suicide among all veterans. Even so, a 10-year prospective strategy should build up, not compromise, VA initiatives. The plan would be improved by explicitly bolstering VA programs that are making a vital difference.
Undercutting VA Suicide Prevention
As my recent review in Federal Practitioner documented, VA’s multiple levels of evidenced-based suicide prevention practices are pre-eminent in the field.2 The VA’s innovative use of predictive analytics to identify and intervene with at-risk individuals is more advanced than anything available in the community. For older veterans who constitute the majority of veterans and the majority of veteran suicides, the VA has more comprehensive and integrated mental health care services than those found in community-based care systems. The embedding of suicide prevention coordinators at every VA facility is unparalleled.
But one would never know about such quality from the National Strategy document: The VA is barely mentioned. The report never advocates for strengthening—or even maintaining—VA’s resources, programs, and efforts. It never recommends that eligible veterans be connected to VA mental health services.
The strategy observes that employment and housing are keys that protect against suicide risk. It does not, however, call for boosting and resourcing VA’s integrated approach that wraps in social services better than does any other program. Similarly, it acknowledges the role of family involvement in mitigating risk but does not propose expanding VA treatments to improve relationship well-being, leaving these services to the private sector.
The National Strategy expands on the recent suicide prevention executive order (EO) for supporting veterans during their transition from military to civilian life. Yet the EO has no funding allocated to this critical initiative. The National Strategy has the same shortcoming. In failing to advocate for more funds to pay for vastly enhanced outreach and intervention, the plan could drain the VA of existing resources needed to maintain its high-quality, suicide prevention services.
First Step: Define the Problem
The National Strategy wisely specifies that the initial step in any suicide prevention effort should be to “define the problem. This involves collecting data to determine the ‘who,’ ‘what,’ ‘where,’ ‘when,’ and ‘how’ of suicide deaths.” Then, “identify risk and protective factors.”
Yet the report doesn’t follow its own advice. Although little is known about the 14 of 20 veterans who die by suicide daily who are not recent users of VA health services, the National Strategy foregoes the necessity of first ascertaining crucial factors, including whether those veterans were (a) eligible for VA care; (b) receiving any mental health or substance use treatment; and (c) going through life crises, etc. What’s needed before reallocating funds to community-based programs is for Congress to finance a post-suicide, case-by-case study of these veteran decedents who did not use VA.
Proceeding in this manner has 2 benefits. First, it would allow initiatives to be targeted. Second, it could preserve funds for successful VA programs that otherwise might be cut to pay for private sector programs.
A Positive Starting Point
There are many positive components of the National Strategy for Preventing Veteran Suicide that will make a difference. That said, they fall short of their potential. The following are suggestions that could strengthen the VA’s plan.
First, given the overwhelming use of firearms by veterans who die by suicide, the National Strategy acknowledges that an effective prevention policy must attend to this factor. It prudently calls for expansion of firearm safety/suicide prevention collaboration with firearm owners, firearm dealers, shooting clubs, and gun/hunting organizations. This will help ensure that lethal means safety counseling is culturally relevant, comes from a trusted source, and has no antifirearm bias.
Nothing would be more useful in diminishing suicide than correcting the false belief among many veterans that “the VA wants to take away our guns.” If that misperception were replaced with an accurate message, not only would more at-risk veterans seek out VA mental health care, more veterans/families/friends would adopt a new cultural norm akin to buddies talk to vets in crisis about safely storing guns. Establishing a workgroup with gun constituency collaborators could spearhead such a shift.
Second, although, the National Strategy emphasizes the benefits of using peer supports, peers currently express qualms that they have too little expertise intervening with this vulnerable population. Peers could be given extensive training and continued supervision in suicide prevention techniques.
Third, the National Strategy calls for expanded use of big data predictive analytics, whose initial implementation has shown great promise. However, it fails to mention that this approach depends on linked electronic health records and therefore best succeeds for at-risk veterans within VA but not in insulated community care.
Fourth, the National Strategy recognizes that reshaping media and entertainment portrayals could help prevent veteran suicide. Yet it ignores the importance of correcting the sullied narrative about the VA. The disproportionate negative image contributes to veterans’ reticence to seek VA health care. One simple solution would be to require that service members readying to transition to civilian life be informed about the superior nature of VA mental health care. Another is to provide the media with positive VA stories more routinely.
Fifth, the National Strategy suggests that enhanced community care guidelines be developed, but it never recommends that community partners should equal VA’s standards. Those providers should be mandated to conduct the same root cause analyses and comprehensive documentation of suicide risk assessments that VA does.
Conclusion
With zero sum department budgets, the National Strategy’s exclusive priority on public health, community-based initiatives could undercut VA successes. An amended plan that explicitly supports and further strengthens successful VA suicide prevention programs is warranted.
1. US Department of Veterans Affairs. National Strategy for Preventing Veteran Suicide, 2018-2028. https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf Published June 2018. Accessed November 6, 2018.
2. Lemle RB. Choice program expansion jeopardizes high-quality VHA mental health Services. Fed Pract. 2018;35(3):18-24.
In June 2018, the US Department of Veterans Affairs (VA) issued its National Strategy for Preventing Veteran Suicide, 2018-2028. Its 14 goals—many highly innovative—are “to provide a framework for identifying priorities, organizing efforts, and contributing to a national focus on Veteran suicide prevention.”1
The National Strategy recognizes that suicide prevention requires a 3-pronged approach that includes universal, selective, and targeted strategies because “suicide cannot be prevented by any single strategy.”1 Even so, the National Strategy does not heed this core tenet. It focuses exclusively on universal, non-VA community-based priorities and efforts. That focus causes a problem because it neglects the other strategies. It also is precarious because in the current era of VA zero sum budgets, increases in 1 domain come from decreases in another. Thus, sole prioritizing of universal community components could divert funds from extant effective VA suicide prevention programs.
Community-based engagement is unquestionably necessary to prevent suicide among all veterans. Even so, a 10-year prospective strategy should build up, not compromise, VA initiatives. The plan would be improved by explicitly bolstering VA programs that are making a vital difference.
Undercutting VA Suicide Prevention
As my recent review in Federal Practitioner documented, VA’s multiple levels of evidenced-based suicide prevention practices are pre-eminent in the field.2 The VA’s innovative use of predictive analytics to identify and intervene with at-risk individuals is more advanced than anything available in the community. For older veterans who constitute the majority of veterans and the majority of veteran suicides, the VA has more comprehensive and integrated mental health care services than those found in community-based care systems. The embedding of suicide prevention coordinators at every VA facility is unparalleled.
But one would never know about such quality from the National Strategy document: The VA is barely mentioned. The report never advocates for strengthening—or even maintaining—VA’s resources, programs, and efforts. It never recommends that eligible veterans be connected to VA mental health services.
The strategy observes that employment and housing are keys that protect against suicide risk. It does not, however, call for boosting and resourcing VA’s integrated approach that wraps in social services better than does any other program. Similarly, it acknowledges the role of family involvement in mitigating risk but does not propose expanding VA treatments to improve relationship well-being, leaving these services to the private sector.
The National Strategy expands on the recent suicide prevention executive order (EO) for supporting veterans during their transition from military to civilian life. Yet the EO has no funding allocated to this critical initiative. The National Strategy has the same shortcoming. In failing to advocate for more funds to pay for vastly enhanced outreach and intervention, the plan could drain the VA of existing resources needed to maintain its high-quality, suicide prevention services.
First Step: Define the Problem
The National Strategy wisely specifies that the initial step in any suicide prevention effort should be to “define the problem. This involves collecting data to determine the ‘who,’ ‘what,’ ‘where,’ ‘when,’ and ‘how’ of suicide deaths.” Then, “identify risk and protective factors.”
Yet the report doesn’t follow its own advice. Although little is known about the 14 of 20 veterans who die by suicide daily who are not recent users of VA health services, the National Strategy foregoes the necessity of first ascertaining crucial factors, including whether those veterans were (a) eligible for VA care; (b) receiving any mental health or substance use treatment; and (c) going through life crises, etc. What’s needed before reallocating funds to community-based programs is for Congress to finance a post-suicide, case-by-case study of these veteran decedents who did not use VA.
Proceeding in this manner has 2 benefits. First, it would allow initiatives to be targeted. Second, it could preserve funds for successful VA programs that otherwise might be cut to pay for private sector programs.
A Positive Starting Point
There are many positive components of the National Strategy for Preventing Veteran Suicide that will make a difference. That said, they fall short of their potential. The following are suggestions that could strengthen the VA’s plan.
First, given the overwhelming use of firearms by veterans who die by suicide, the National Strategy acknowledges that an effective prevention policy must attend to this factor. It prudently calls for expansion of firearm safety/suicide prevention collaboration with firearm owners, firearm dealers, shooting clubs, and gun/hunting organizations. This will help ensure that lethal means safety counseling is culturally relevant, comes from a trusted source, and has no antifirearm bias.
Nothing would be more useful in diminishing suicide than correcting the false belief among many veterans that “the VA wants to take away our guns.” If that misperception were replaced with an accurate message, not only would more at-risk veterans seek out VA mental health care, more veterans/families/friends would adopt a new cultural norm akin to buddies talk to vets in crisis about safely storing guns. Establishing a workgroup with gun constituency collaborators could spearhead such a shift.
Second, although, the National Strategy emphasizes the benefits of using peer supports, peers currently express qualms that they have too little expertise intervening with this vulnerable population. Peers could be given extensive training and continued supervision in suicide prevention techniques.
Third, the National Strategy calls for expanded use of big data predictive analytics, whose initial implementation has shown great promise. However, it fails to mention that this approach depends on linked electronic health records and therefore best succeeds for at-risk veterans within VA but not in insulated community care.
Fourth, the National Strategy recognizes that reshaping media and entertainment portrayals could help prevent veteran suicide. Yet it ignores the importance of correcting the sullied narrative about the VA. The disproportionate negative image contributes to veterans’ reticence to seek VA health care. One simple solution would be to require that service members readying to transition to civilian life be informed about the superior nature of VA mental health care. Another is to provide the media with positive VA stories more routinely.
Fifth, the National Strategy suggests that enhanced community care guidelines be developed, but it never recommends that community partners should equal VA’s standards. Those providers should be mandated to conduct the same root cause analyses and comprehensive documentation of suicide risk assessments that VA does.
Conclusion
With zero sum department budgets, the National Strategy’s exclusive priority on public health, community-based initiatives could undercut VA successes. An amended plan that explicitly supports and further strengthens successful VA suicide prevention programs is warranted.
In June 2018, the US Department of Veterans Affairs (VA) issued its National Strategy for Preventing Veteran Suicide, 2018-2028. Its 14 goals—many highly innovative—are “to provide a framework for identifying priorities, organizing efforts, and contributing to a national focus on Veteran suicide prevention.”1
The National Strategy recognizes that suicide prevention requires a 3-pronged approach that includes universal, selective, and targeted strategies because “suicide cannot be prevented by any single strategy.”1 Even so, the National Strategy does not heed this core tenet. It focuses exclusively on universal, non-VA community-based priorities and efforts. That focus causes a problem because it neglects the other strategies. It also is precarious because in the current era of VA zero sum budgets, increases in 1 domain come from decreases in another. Thus, sole prioritizing of universal community components could divert funds from extant effective VA suicide prevention programs.
Community-based engagement is unquestionably necessary to prevent suicide among all veterans. Even so, a 10-year prospective strategy should build up, not compromise, VA initiatives. The plan would be improved by explicitly bolstering VA programs that are making a vital difference.
Undercutting VA Suicide Prevention
As my recent review in Federal Practitioner documented, VA’s multiple levels of evidenced-based suicide prevention practices are pre-eminent in the field.2 The VA’s innovative use of predictive analytics to identify and intervene with at-risk individuals is more advanced than anything available in the community. For older veterans who constitute the majority of veterans and the majority of veteran suicides, the VA has more comprehensive and integrated mental health care services than those found in community-based care systems. The embedding of suicide prevention coordinators at every VA facility is unparalleled.
But one would never know about such quality from the National Strategy document: The VA is barely mentioned. The report never advocates for strengthening—or even maintaining—VA’s resources, programs, and efforts. It never recommends that eligible veterans be connected to VA mental health services.
The strategy observes that employment and housing are keys that protect against suicide risk. It does not, however, call for boosting and resourcing VA’s integrated approach that wraps in social services better than does any other program. Similarly, it acknowledges the role of family involvement in mitigating risk but does not propose expanding VA treatments to improve relationship well-being, leaving these services to the private sector.
The National Strategy expands on the recent suicide prevention executive order (EO) for supporting veterans during their transition from military to civilian life. Yet the EO has no funding allocated to this critical initiative. The National Strategy has the same shortcoming. In failing to advocate for more funds to pay for vastly enhanced outreach and intervention, the plan could drain the VA of existing resources needed to maintain its high-quality, suicide prevention services.
First Step: Define the Problem
The National Strategy wisely specifies that the initial step in any suicide prevention effort should be to “define the problem. This involves collecting data to determine the ‘who,’ ‘what,’ ‘where,’ ‘when,’ and ‘how’ of suicide deaths.” Then, “identify risk and protective factors.”
Yet the report doesn’t follow its own advice. Although little is known about the 14 of 20 veterans who die by suicide daily who are not recent users of VA health services, the National Strategy foregoes the necessity of first ascertaining crucial factors, including whether those veterans were (a) eligible for VA care; (b) receiving any mental health or substance use treatment; and (c) going through life crises, etc. What’s needed before reallocating funds to community-based programs is for Congress to finance a post-suicide, case-by-case study of these veteran decedents who did not use VA.
Proceeding in this manner has 2 benefits. First, it would allow initiatives to be targeted. Second, it could preserve funds for successful VA programs that otherwise might be cut to pay for private sector programs.
A Positive Starting Point
There are many positive components of the National Strategy for Preventing Veteran Suicide that will make a difference. That said, they fall short of their potential. The following are suggestions that could strengthen the VA’s plan.
First, given the overwhelming use of firearms by veterans who die by suicide, the National Strategy acknowledges that an effective prevention policy must attend to this factor. It prudently calls for expansion of firearm safety/suicide prevention collaboration with firearm owners, firearm dealers, shooting clubs, and gun/hunting organizations. This will help ensure that lethal means safety counseling is culturally relevant, comes from a trusted source, and has no antifirearm bias.
Nothing would be more useful in diminishing suicide than correcting the false belief among many veterans that “the VA wants to take away our guns.” If that misperception were replaced with an accurate message, not only would more at-risk veterans seek out VA mental health care, more veterans/families/friends would adopt a new cultural norm akin to buddies talk to vets in crisis about safely storing guns. Establishing a workgroup with gun constituency collaborators could spearhead such a shift.
Second, although, the National Strategy emphasizes the benefits of using peer supports, peers currently express qualms that they have too little expertise intervening with this vulnerable population. Peers could be given extensive training and continued supervision in suicide prevention techniques.
Third, the National Strategy calls for expanded use of big data predictive analytics, whose initial implementation has shown great promise. However, it fails to mention that this approach depends on linked electronic health records and therefore best succeeds for at-risk veterans within VA but not in insulated community care.
Fourth, the National Strategy recognizes that reshaping media and entertainment portrayals could help prevent veteran suicide. Yet it ignores the importance of correcting the sullied narrative about the VA. The disproportionate negative image contributes to veterans’ reticence to seek VA health care. One simple solution would be to require that service members readying to transition to civilian life be informed about the superior nature of VA mental health care. Another is to provide the media with positive VA stories more routinely.
Fifth, the National Strategy suggests that enhanced community care guidelines be developed, but it never recommends that community partners should equal VA’s standards. Those providers should be mandated to conduct the same root cause analyses and comprehensive documentation of suicide risk assessments that VA does.
Conclusion
With zero sum department budgets, the National Strategy’s exclusive priority on public health, community-based initiatives could undercut VA successes. An amended plan that explicitly supports and further strengthens successful VA suicide prevention programs is warranted.
1. US Department of Veterans Affairs. National Strategy for Preventing Veteran Suicide, 2018-2028. https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf Published June 2018. Accessed November 6, 2018.
2. Lemle RB. Choice program expansion jeopardizes high-quality VHA mental health Services. Fed Pract. 2018;35(3):18-24.
1. US Department of Veterans Affairs. National Strategy for Preventing Veteran Suicide, 2018-2028. https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf Published June 2018. Accessed November 6, 2018.
2. Lemle RB. Choice program expansion jeopardizes high-quality VHA mental health Services. Fed Pract. 2018;35(3):18-24.