Mental Illness and Violence

In the past couple of years we have witnessed an alarming number high profile mass murders perpetuated by those with histories of serious mental illness. From Sandy Hook, New Jersey to Aurora, Colorado, and more recently to Oregon those with apparently severe mental illness have been able to obtain high powered rifles and astounding amounts of ammunition enabling them to act out their delusions and/or homicidal and suicidal thoughts in a public place on innocent people. (Adam Lanza's mother bought the guns used not only to kill her, but also the children and their teachers at Sandy Hook.)

As a nation we are horrified and wring our hands about what can be done. First of all let us acknowledge that the vast number of seriously mental ill people are not violent. Indeed, they are more likely to be victims of crime that to perpetrate crimes. Second, any mental health professional, including forensic psychiatrists, will acknowledge the difficulty in determining that a particular individual is dangerous and might commit such crimes. Although when a mental health worker believes that someone is a danger to self and/or others, that person can be committed to a mental health facility, usually 72 hours, for an evaluation. However, given the state of mental health care even those who come to the attention of mental health professionals may slip through the cracks and fail to receive a competent evaluation.

Persons who have been in and out of mental health facilities and have long histories of serious illness coupled with non-compliance with prescribed medication and failure to maintain a relationship with out-patient clinics should not have access to fire arms of any kind. While their names might appear on the government "no sale" list and they may be denied access to guns from a legitimate dealer, anyone, no matter how ill, can obtain military style weapons from gun shows, estate sales, and individuals. No questions asked, except perhaps age, and a seriously mentally ill, often delusional (believing things that are not real), perhaps hallucinating (seeing things that are not real) can obtain weapons and rounds of ammunition. They typically gain entry to a public place, like a movie theater or small town elementary school, and commit mass murder.

The madness of allowing anyone with a few hundred dollars to purchase guns will have to be addressed before such horrific incidences will stop! Without adequate mental health care and improved gun regulation, each one of us will continue to be in danger!

He Did the Unthinkable

The world was shocked and horrified by the actions of severely depressed pilot, Andreas Lubitz, who committed suicide by slamming an airplane filled with passengers into a mountain. As the investigation continues, we learn of his history with mental illness and the note in Lubitz's trash can from his psychiatrist stating he was unfit for work due to his severe depression. Lubitz did the unthinkable, even his doctor must have felt incredulous horror at his actions.

Only a tiny fraction of those with mental illness carry out violent acts. However, approximately 1 in 4 persons in the United States has a diagnosable mental illness in any one given year. This statistic is remarkably consistent across the world. Yet we continue to either ignore mental illness, push it to the back burner of health care, or stigmatize the sufferer, wringing our collective hands when the seriously ill commit the unthinkable, like Lubitz or mass murderer Adam Lanza in Sandy Hook, New Jersey.

As a society, we behave as though we cannot afford to treat mental illness, do not know how to treat it, make it a civil rights or privacy issue, or ignore the problem, hoping it will simply go away. All of these attitudes led to the current state of mental health care - which in too many cases is no care or grossly inadequate care.

In reality, we cannot afford not to treat mental illness.  Most mental illness are chronic diseases, once it develops one is seldom cured, but rather the disease is managed, much like diabetes. We now know that most mental illnesses are diseases of the brain - the brain is mal-functioning, much like many chronic illnesses effecting other organs of the body. Mental illness can be treated and successfully managed. Advances in treatment, especially medications, allow those who suffer with many mental illnesses to live and work successfully - if they continue with  treatment. Lack of compliance with extended treatment is a major issue leading often to the return of symptoms.

Treatment costs money - just as any other chronic illness management requires the expenditure of resources. Research is costly, but research into the causes and effective treatments of complex diseases of the brain is desperately needed.

Fortunately, we are beginning to come out of denial and deal with this pandemic - we have a very long way to go and if we scurry back into our denial, we not only increase the suffering of those afflicted with mental illness and their families, we guarantee yet another mass murder.

Why Does She Stay?

                                                       Why Does She Stay?

                                           It is Not Just About The Beatings!

When NFL player Ray Rice punched his then fiancé and mother of his child, Jaylan, knocking her unconscious and dragging her (though he could have quite easily carried her) out of an elevator, many who viewed the tape asked the question "Why did she stay with him?" Not only did she stay, but she married him several days later!

I do not know about the personal lives of  Mr. and Mrs. Rice, but the circumstances are not uncommon and the question "Why did she (or he) stay?" is one often asked by those not familiar with the circumstances surrounding domestic abuse. The reasons are many and most have to do with the complex nature of intimate partner abuse. In other words, it is not just about the beatings.

Of the 2 million injuries and 1,300 deaths each year in the United States resulting from domestic abuse, the most dangerous time is when the victim attempts to leave. Domestic abuse is about control, control of the victim and when the perpetrator feels the loss of control they will often increase the violence and the threats. The perpetrator may threaten to kill not only the victim, but their children, parents, other family members, and even pets. The victim, terrified the perpetrator will act on these threats, feels they must stay in order to save their own life as well as others. The perpetrator may also threaten to kill themselves. The victim often feels they cannot live with themselves should the suicide threat be carried out.

Very few abusive relationships are violent on a daily basis, instead there is often a cycle of abuse. The cycle begins with an abusive episode, after which the victim may threaten to leave and the remorseful abuser responds with pleas for forgiveness, promises to change, and demonstrations of gifts and affection. This is called the "honeymoon period." Jaylan Rice has probably enjoyed quite a honeymoon. They were quickly married, likely something she has wanted for a long time since they had been together since high school and have a child. He praises and thanks her publicly and is probably acting like the man she always wanted. Since he is wealthy the gifts are likely plentiful and expensive.

The "honey moon period" gives way to mounting tension between the couple. Most victims sense the coming abuse and attempt to modify their own behavior to prevent or they may provoke it, just to end the tension and get it over with. Inevitability the abuse will occur, bringing the cycle full circle.

Abuse is not only physical, it is psychological. Perpetrators often tell the victim if they leave no one will ever want them, they will be alone for the rest their lives, or you are too stupid to care for themselves. Even the most attractive and capable person will eventually come to believe such negative programing especially, if it comes from someone who has said they love them. Low self-esteem and doubt generates an absolute terror of being alone. A former client once told me about what would happen to her if she ended an abusive relationship, "I disappear." She believed this despite exceptional attractiveness and a college education.

Other reasons for staying include believing that abuse means love, "If you will get mad enough to hit me, you love me, just don't ignore me." Or "If you are jealous enough to hit me, then you most love me." This dynamic often occurs when the victim has witnessed or has been the victim of  abuse and neglect as a child.

Those with children may believe living in an a home with an abusive, violent relationship is better than being in a single parent home. In reality, witnessing abuse between parents is terribly damaging to children, teaching them to enter into their own abusive relationships.

Even in this day of more egalitarian marriages and information about the effects of abusive relationships, women are often told by male religious figures or family members, including their mothers, that it is her responsibility to keep the marriage together and she must be doing something to provoke the abuser. It is her duty to change her behavior.

Small wonder most abuse victims find it so difficult to leave or to press charges against the abuser. Men find it particularly difficult to admit to themselves and to others they are being abused by their female spouse. Gay or lesbian couple's may also find themselves caught in an abusive relationship. When a victim does find the motivation and the courage to leave the relationship, it is imperative that she or he find compassion, community support, and the resources to make this dangerous, total life change.

Current State of Mental Health Care:Finding Help

If you believe physical health care is in a state of disrepair, then you have not attempted to enter the mental health care system. It is in a far more chaotic and dysfunctional state than any portion of the medical health care system.

In my community, a moderately sized city, if one requires mental health services for a serious mental health crisis, for instance, severe depression, worsening of a bi-polar condition, or schizophrenia, there are several choices.

First, if one is insured, there are two private psychiatric hospitals. They can admit patients who are in crisis, that is, one is "a danger to self or others."  If one is not suicidal or homicidal, getting an out-patient appointment with a psychiatrist may take more than six weeks, especially if one does not have a previous relationship with the physician. A psychiatrist may admit a patient who does not meet the criteria for a crisis admission, but insurance companies may deny the admission in favor of out-patient treatment. If the insurer does permit admission, the length of stay will likely be limited to less than ten days.

Second, there is a state psychiatric hospital. The admission criteria is the same as the private hospitals, with one important exception. The state hospital must admit and evaluate anyone arrested for a violent or serious property crime, if a judge suspects they are mentally ill. Most such persons will eventually stand trial and, if found guilty, will be incarcerated.

If one requires out-patient services, there are non-profit mental health clinics where one might see a counselor or clinical social worker. A psychiatrist will supervise the care and will schedule a brief appointment if medications or substantial changes in medications are needed. Fees are generally on a sliding scale. Such non-profit clinics are extremely busy and wait times for an appointment may be several weeks.

There are also a number of counselors and therapists in private practice. Their credentials range from Clinical Psychologist, Licensed Professional Counselor, Clinical Social Worker, Nurse Practioner, Licensed Substance Abuse Counselor, or  Pastoral Counselor. All of these persons have training and legitimate credentials, but since any one may call themselves a counselor in Tennessee, it pays to ask questions. Many well creditaled therapists (counselor and therapist are often used interchangbly) may file for insurance reimbursement, but insured visits are limited, even if one is referred by their employer's Employee Assistance Program. Reimbursement may not cover the over $100 an hour fees of many therapists. However, most private practice therapists can see clients in less than two weeks.

There you have it. Not many good options. My community is probably not substantially worse or better than most communities, with the exception of a state hospital which gives one additional option. Small wonder so many people are not getting appropriate care and continue to suffer, as do their families. Suffering may be a part of life, but much of it is optional and as a nation we have chosen not to invest the resources to relieve the suffering of those we call mentally ill.

 

Men and Women Differ When they Suffer From Depression By Gay Moore M.Ed. RNC

Dave spends most of his time working, watching sports on TV, and playing computer games. Uncommunicative and uninvolved, he seems to have lost interest in his family. He often has difficulty sleeping or sleeps most of his non-working hours. His interest in lovemaking is practically non-existent, and he has an increasing number of vague physical complaints. Small matters upset him out of proportion to the seriousness of the situation. He complains about his work and has difficulty getting along with others. Pleasing him is nearly impossible and he is increasingly pessimistic. In short, living with him is increasingly frustrating. Rather than being deliberately difficult, he may be depressed.

Depression is often considered a women’s disease, even by physicians and pharmaceutical companies. Women are often pictured in those glossy drug company advertisements and physicians are generally alert to the signs of depression in their female patients. The Diagnostic and Statistical Manual of the American Psychiatric Association (the manual that describes mental illnesses for purpose of diagnosis)  describes depression as a complex of symptoms: loss of interest in previously pleasurable activities; decreased sexual desire; difficulty sleeping or over-sleeping; weight gain or loss when not seeking to do so; increased agitation, anger, hostility or over-reacting; increased pessimistic thinking and feelings of hopelessness; vague physical complaints in the absence of identifiable illness; loss of energy; and feeing as of guilt and thoughts of suicide.

While research indicates that women are twice as likely to be diagnosed with depression as men, one in six men will suffer from depression at some time in their lives, as compared to one in four women. However, men often exhibit different symptoms than women. Women are more likely to acknowledge and verbalize feelings of sadness and hopelessness. Men are more likely to follow the pattern of adolescents and children, experiencing increased irritability, agitation, withdrawal from others, loss of energy, and physical complaints. This is especially true in more moderate episodes of depression.

When we look at the other symptoms of depression: markedly diminished interest and pleasure in almost all activities, insomnia or over-sleeping, weight gain or loss when not dieting, agitation or loss of energy, and difficulty concentrating, a picture of male depression emerges.

If you suspect a man in your life is depressed, convincing him to seek treatment may be difficult. Many men see depression as a woman’s illness and a sign of weakness. Suggestions that he see a psychiatrist or counselor may be met with angry denial. However, you may be able to convince him to see a physician for his lack of energy or other physical complaints.  While one can not count on a physician detecting depression in a man who is an expert at looking “okay,” if you have a good relationship with his doctor you might inform the physician of your observations and suspicions prior to the visit.

A supportive, non-accusatory discussion may induce him to consider the possibility. Giving him information from the Internet or even this article may convince him to seek help.

Fortunately, medicines developed in the past few years can effectively treat depression. The newer drugs are relatively free of side effects, and if side effects, especially sexual side effects, develop a different medicine can be substituted. Research shows that combining medication with counseling is the most effective treatment for depression. The Employee Assistance Program at his place of work or a member of the clergy may be more acceptable to him, but certainly there are many good counselors and psychologists who can assist him.

Even if he refuses to seek professional help, there is still hope for improvement and possible recovery. Most depressive episodes are self-limited and some improvement is likely even if he receives no treatment.

The better news is that mild to moderate depression responds well to aerobic exercise. Researchers at a number of different institutions indicate that exercise has multiple benefits in helping manage depression. Indeed, up to 90% of research participants report some relief from depression by following an exercise regime.  Research conducted at the Mayo Clinic indicates that “exercise positively affects the levels of certain mood-enhancing neurotransmitters in the brain.”  Some researchers believe that regular exercise alters the levels of two neurotransmitters found in the brain, serotonin and endorphins, leading to elevation of mood and easing of depression.

Furthermore, exercise tends to promote better sleep, increased energy, and a sense of calm self-control, as well as providing a distraction from cycles of pessimistic thinking. Since exercise is generally done outside and with others, there is even a mood elevating benefit from increased sunlight and decreased isolation.

Almost any enjoyable physical activity may result in decreased depression. Walking, biking, jogging, swimming, softball, and weight lifting, even dancing, yoga or Taekwondo, will likely reap beneficial results. (Exercise with him. Living with someone who is depressed is depressing and exercise may well help you as well.) The best news is that research indicates that even 30 minutes a day three to five times a week is helpful. Exercise “may not be the magic bullet, but increasing physical activity is a positive and active strategy to help manage depression and anxiety,” according to Mayo Clinic psychologist, Dr. Kristin Vickers –Douglas.

Combining appropriate medication with counseling and increased activity often leads to dramatically improved mood and functioning.

Depression is one of the most successfully treated emotional illnesses, but failure to treat it may result in more than living with a grumpy coach potato. While more depressed women attempt suicide, depressed men are more likely to actually die by suicide. So act and act forcefully. You may not only improve the life of a man you love, but you might also save it.

 

For more information check out the following websites:

www. overcoming-depression.com/man-and-depression.html www.mayoclinic.com/health/depression-and-exercise/MH00043 www.betterhealth.ic.gov.au/bhcv2/bhcarticles.nsf/pages/Depression_andexercise  

Interview with Brennan Francois, MS Chief Executive Officer Parkridge Valley Hospital

Recently I sat down with CEO Brennan Francois in his office at Parkridge Valley Hospital, a local psychiatric facility owned by HCA Healthcare, to discuss some of the major issues confronting mental health care.

Personable and articulate, Mr. Francois began his career in mental health care while still in college with Parkridge Valley as a technician in the adolescent treatment unit. Rising through the ranks to his current position, he has seen psychiatric care from the point of view of an entry level employee through his current CEO position.

When asked about the some of the major issues impacting the delivery of mental health services, he immediately stated that while Congress passed the Mental Health Parity Act some years ago, requiring insurers to pay for mental health care at the same level as physical health care, the regulations as to how such parity is to be achieved have yet to be passed by Congress and implemented by the Department of Health and Human Services.

Thus insurances companies continue to reimburse providers at sub-parity levels resulting in short hospital stays (six days on average) which are woefully to adequately treat serious mental illness. Add to this the lack of out-patient resources to provide continuing care and we have a national mental health care system that is in crisis. Small wonder that jails and prisons have become de-facto treatment options for many mentally ill persons.

Anther factor adding to the difficulties faced by those who access the mental health treatment system is a shortage of psychiatrists, resulting in wait times for non-emergency out-patient appointments of up to six to eight weeks.  Mr. Francois stated that the region which includes Hamilton and several surrounding counties is currently twenty-eight full-time psychiatrists short.

Another issue is the shortage of both private and public in-patient beds. This is coming at time of not only stagnant re-imbursement rates to private hospitals, but also in the wake of dramatic reductions in funding for state regional psychiatric hospitals.

Mr. François would also like to see an increased number of psychiatric beds designated for the treatment of young adults, 18 to 25 years of age. At present, an in-patient psychiatric unit may include three or four generations, often negatively impacting the therapeutic milieu when younger patients, who may be more disruptive and who certainly have different life concerns, are housed with older adults.

 

Mental illness is seldom a discrete, acute condition, which can be “cured” with a single in-patient stay. Instead, most psychiatric conditions, like major depression, bi-polar disorder, and schizophrenia, are chronic. Thus clients require a continuum of care from in-patient hospitalization to out-patient counseling and community services. Such services are currently over-stretched and inadequate. Mr. François cites the need for more social workers to assist clients in managing chronic illness and group homes for those who experience difficulty functioning outside of a structured environment. He also cited the need for respite care for the high percentage of the mentally ill who are cared for by family members, as well as medical group homes for those who suffer from chronic medical illness as well as mental illness.

 On the positive side, Mr. François sees the increased use of partial hospitalization and intensive out-patient programs as effective ways of helping clients avoid repeat hospitalizations.  Increased partnering and cooperation among mental health providers, including the local Crisis Response Team, is also a positive development. Additionally, the local sheriff’s department and county jail personnel have received intensive training in handling mental health issues which has also netted positive results. He also cited the increased presence of specialized dementia assessment and treatment units as a positive approach in meeting the needs of the growing elderly population.

When asked how health care reform will impact mental health care, Mr. Francois reiterated that while there is much uncertainty about the effects of new government policies and regulations, he hopes that health care reform will finally result in parity for psychiatric treatment and increased incentives for cooperation and collaboration among mental health care providers.

Generational Clashes in Healthcare