My friend and colleague Abe Halpern passed away on April 20, 2013. Abe was a remarkable and unforgettable person. He was a loving and dedicated husband, father, grandfather and and great grandfather.  He also was a skilled forensic psychiatrist and an activist for many the causes in which he deeply cared about.

Abe and I belonged to the same District Branch (Westchester Psychiatric Society) of the American Psychiatric Association and were both on the faculty of New York Medical College in Valhalla, New York, so I had numerous opportunities to see him in action. I also observed him stand up for his beliefs at the Assembly of the American Psychiatric Association where he introduced various resolutions which were passed due to his persuasive advocacy. He was a reader of this blog and was kind enough to frequently make constructive suggestions to me.

I had the opportunity to sit and down  and conduct a one to one  recorded interview with Abe where he discussed three topics which were dear to his heart. This interview is presented below in three parts:

Part One  – Is there a role for a psychiatrist in the care of a prisoner who is being executed?

Part Two – Is there a role for a psychiatrist in the questioning of a prisoner?

Part Three – Should Marijuana be legalized ?

Born 2/2/1925. Died 4/20/2013 as a result of an earlier fall. His family emigrated to Canada in 1927. As a teenager, he joined the Royal Canadian Navy serving in both the Atlantic and Pacific theaters during WWII. After the Korean War, he was honorably discharged at the rank of Lieutenant Surgeon Commander. A medical school graduate of the University of Toronto, he practiced psychiatry for over 50 years and was a leader in the subspecialty of forensic psychiatry. Awards from the American Medical Association, American Psychiatric Association, and from many other organizations of medicine reflect a life dedicated to human rights. He marched with Martin Luther King, Jr. in Selma, fought against China’s torture of the Falun Gong and illegal organ transplantation, the misuse of the insanity defense, and forced psychiatric hospitalization without judicial review. He was a national and international leader against the involvement of physicians in capital punishment and also physician participation in coerced interrogations of prisoners. All were subject of his prolific publications. He is survived by his beloved wife Marilyn, and his loved children (and spouses) Howard, Lon (Barbara), Marnen (Herdis), Chaia (Adam), Mark (Tomoko), Emily, and John. He was an adoring grandfather of 11 and great-grandfather of 5.

Suicide is the 11^th leading cause of all death in the United States. It is one of most important issues which mental health professionals are concerned about in their clinical work. The American Academy of Psychoanalysis and Dynamic Psychiatry of which I have the honor of currently being President, has designated the title of its 57^th annual meeting as: Psychodynamics: Essential to the Issue of Suicide and Other Challenges to Modern Day Psychodynamic Psychiatry.  It is fitting that the meeting is being held in San Francisco which although not on the top 15 cities with the highest suicide rate does have the Golden Gate Bridge as its symbol which is the second most common suicide site in the world.(see previous posts on this subject)  Any mental health professional is cordially invited to register and attend this meeting (see AAPDP.org) which will take place May 16-18 2013.

Mental health professional must always consider the suicidal potential of any patient especially when that patient is depressed or experiences significant distress. I recall as a junior psychiatry resident when I first was given the responsibility of making a decision to hospitalize  patients (even against their will) because I felt he or she was a danger to themselves (or others). As much as this is a heavy burden, it is likewise a major responsibility not to hospitalize a suicidal patientand face a situation where this person has ended their own life.  In the latter case there also is the possibility of legal consequences.

If a person is determined to end his or her own life, they will ultimately succeed. However when the desire to do it is due to a mental condition that we can treat, there is a good chance that we can prevent the suicide if we can intervene and facilitate proper treatment. Unfortunately this is not always the case since patients who are in treatment or who have had treatment do kill themselves.

Depression is the most common condition which has the potential to lead to suicide. This may be part of biological condition with genetic components which brings about severe bouts of depression. Depression may be part of the grieving process or it may be due to complicated psychological reasons which lead  some people  to be so depressed that they want to end their life.

Sometimes there is anger at a lost object (person) that gets turned inward leading to self destructive acts. When the ability to test reality is lost, the  reasoning for suicidal actions can be quite bizarre and may include internal voices commanding the persons to hurt or kill themselves. There are still other situations where a person does a self destructive act, not with intent to commit suicide but rather with an intent to suffer or manipulate others but inadvertently does die as a result of this gesture. There are certain personality patterns where there may be repeated suicidal gestures which have the potential to be fatal or very harmful. Drugs and alcohol and complicate the problems and may actually be the cause of suicide.

There are some special circumstances where a patient with a serious, very painful  or perhaps  fatal illness may want to end his or her life or may ask the doctor  to facilitate their demise. There are ethical discussions how should this be handled. In some of these situations, if pain and discomfort is better controlled this may not be an issue.

The treatment for a patient with suicidal potential is a delicate situation. First the decision needs to be made if the treatment is to be inpatient or outpatient (sometimes a combination of both). There needs to be a treatment plan that will almost always require psychotherapy frequently with a combination of psychopharmacology. In rare situations ECT (Electric Convulsive Treatment) will be utilized. Family and close friends often play an important role in the support of the person with suicidal thoughts. While psychotherapy needs to be confidential, the patient needs to understand that under certain circumstances where the therapist believes that the patient is an immediate danger to self or others, the therapist may have to break the confidentiality for the benefit of the patient. It goes without saying that there needs to be a trusting relationship with the therapist so the patient understands that there are two people working together in the best interest of the patient.

Many of these  topics and others  are going to be addressed at the San Francisco meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry  May 16-18 at the Westin St Francis Hotel which was mentioned at the beginning of this blog.  All mental health professionals are welcome to register  either in advance or onsite and attend the meeting . Go to AAPDP.org for more information or you can contact me if there are any questions. There will three plenary sessions by Drs Mardi Horowitz, Jeste Dillip and Herbert Pardes as well as  many panels and workshops. There will also be a very interesting documentary about suicide titled, Don’t Change The Subject  with a discussion with Mike Stutz,  the filmmaker after it is shown. A few of these presentations will be made available to Auto-Digest subscribers but if you are able to attend in person, I suggest that you  do so. I look forward to meeting any attendees at the meeting.

President’s Message: My Introduction to Telemedicine/Telepsychiatry

By Michael Blumenfield, M.D.

There are many psychiatrists and other therapists who have been involved for at least several years with using   computers and video cameras through the Internet to see patients and teach. From time to time over the years I have attended presentations that described the pros and cons of this activity. I recall some of my skeptical colleagues saying until you can smell the patient, they were not getting involved. I always thought that was extreme but recall another statement bandied around that you have to be able to get a very good look into the patient’s eyes in order for this technique to be useful. Still others likened this approach to therapy on the telephone which some favored in rural areas with circumstances where there were no access to in-person therapists.

My interest in this subject was renewed about 3 years ago when I left New York Medical College. I established a practice in Los Angeles and began to explore some new venues. Dr. Elise Snyder asked me if would like to teach and do other activities with the Chinese American Psychoanalytic Alliance program (CAPAChina.org) that used SKYPE and OooVoo to teach classes, supervise therapists, and treat therapists who were in their training program. By this time I had experience using SKYPE communicating with family members and sharing some travel experience live online from far away countries.

CAPA is an extremely well organized program that continues to grow and offers eager Chinese therapists a chance to receive a high-quality two year training program in psychoanalytic therapy. Within a short time after connecting with them, I could not believe that I was sitting in my office talking and interacting with 10-12 Chinese students in three different cities. Needless to say, I do not speak Chinese and to be accepted into the program the Chinese students must be fluent in English.

I was re- reading and discussing some classical psychoanalytic papers which I hadn’t read in many years. I was also learning about some subtle cross cultural concepts. For example, the concept of shame in China is a very important one and is quite different than the concept of guilt which is so important in western culture. I recall one homework exercise I gave the students which was to discuss clinical examples of shame in their therapy work or alternatively from their own life experience. One bright student told how he as a young boy would make up stories of things he said that he did wrong order to show shame which pleased his grandparents and made them very happy.

The opportunity to do one to one supervision and also some individual psychotherapy also revealed new issues reflecting the Chinese experience. For example, a patient after several months in treatment began to mention that when she was five years old, she and her family had to move to the countryside. Her memories about that time seemed to be very benign. Doing some calculations in my mind about the little Chinese history that I did know, I inquired if that wasn’t a difficult time when many people were being punished and treated badly as part of “re-education “ measures. This inquiry led her to begin to rock and back and forth and cry as she recalled that that was a terrible time in the history of her family.

In other ways the issues of trust, speaking freely and the resistances to doing so are important in therapy but are colored by the Chinese culture and the prevailing changing atmosphere in China. All this was very enlightening to me and emerged from my limited work with CAPA and telepsychiatry. My work with CAPA led to me to going on a CAPA study tour where I was able to lecture in China, meet some the students in person and attend the student graduation program in Beijing.

Our experience with CAPA led my colleague Dr. Jim Strain and I to set up a non-profit teaching program in Psychosomatic Medicine for third world countries (PSMWW.com). We had decided to do this rather than write a second edition for a large textbook we edited in the above field. We thus far have taught two 8-session courses in South America and in Rwanda via teleconferencing. One of the systems we use allows us to share our computer screen and that makes the projection of PowerPoint sides particularly useful. However the most meaningful part of the teaching is the direct interaction with the students. This exposure, and the nature of the teaching material we have chosen that is greatly influenced by psychodynamic experience, is also proving to be  interesting from a cross cultural point of view.

I had a completely different experience when I signed up to work one half-day a week with the California Telepsychiatry Group (caltelepsych.com/) that is part of American Telepsychiatrists led by Dr. John Schaffer. This group has a contract to provide psychiatric care via video conferencing for several mental health clinics in central California. They use a system called Web-Ex which seems to be even better than SKYPE and OOVOO. They also have a sophisticated online electronic medical record that I can easily access as well as an online prescribing system called Infoscriber where I can directly prescribe to any pharmacy in California.

American Telepsychiatrists has many other sophisticated features. The sessions take place in a private room in a clinic while I am comfortably in my office in Los Angeles.  I  have a psychiatric nurse present with the patient and/or a translator when needed. While I am doing mainly psychopharmacology, I can refer the patient to individual and group therapy, to primary care physicians, and to substance abuse programs, and I can order lab work, communicate with other health care workers, and send patients directly to the hospital or do anything that I might do from my private office. The psychiatric nurse with whom I work, and the staff, are helpful and supportive. Patients adjust easily to this form of communication and most of them are extremely appreciative of the care that they are receiving.

Only recently have I considered using telepsychiatry in my private office practice. There were two instances where college students with whom I was working were going back to college and they wanted to continue their sessions while they were away at school. They were very comfortable with SKYPE and one of them used it on his i-phone. The therapy didn’t miss a beat. One session took me zooming from room to room as the student’s roommate had unexpectedly appeared and the patient was trying to keep his therapy confidential.

I started using SKYPE to treat a new patient who was from another city and expected to be traveling to Los Angeles from time to time for occasional face-to-face sessions. Of course resistance and transference issues have to be considered when there is the lack of an in-person presence. Recently a patient being seen through SKYPE asked if I would mind if he lit up a cigarette. That issue hasn’t come up in over 20 years since I removed the ash trays from my office. So while the smoke wouldn’t bother me, of course I had to explore the patient’s state of mind for wanting to light up at that time.

We are becoming more of a global society. AAPDP is having an increasing number of international members. We comfortably travel in airplanes and through the Internet. It seems only logical that we should take our professional lives with us on these journeys.

IMPORTANT ADDENDUM: Please see link to an important statement about this topic at the end of the blog

I personally favor strict gun control laws. I also believe that that there should not be stigma against people with mental illness. People should be able to see a mental health professional with the confidence that their treatment will be confidential. The exception to this latter point is when the mental health professional believes that the person is  a danger to themselves or someone else, the mental health professional is obligated to act and notify police if indicated and/or hospitalize the patient. This obligation should not be a secret to the patient and anyone seeing a therapist should understand that would be  the appropriate and ethical behavior to be followed in those circumstances.

There may very well be a conflict in the first sentence in the above paragraph and the statements which follow. My thinking about this subject was stimulated by a recent op-ed piece in the NY Times  by Ms. Wendy Burton a former political speech writer titled “Please Take Away My Right to a  Gun” . Ms Burton argues although she might be tempted to get a gun for self protection she also realizes that her depression condition would make her more likely to use it against herself.

She quotes statistics from the Center for Disease Control and Prevention that 38,364 Americans committed suicide in 2010 and 19,392 used a gun.

Federal Law Concerning Mental Illness and Right to Own a Gun

Possession of a firearm by the mentally ill is regulated by both state and federal laws.  The federal law  states “ It is unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person “has been adjudicated as a mental defective or has been committed to any mental institution.” Mentally defective is obviously an outdated term and I am guessing that would probably be interpreted to mean mentally disabled. (meaning low IQ or significant brain damages etc ). I assume that the term “committed“ to a mental institution means some type of  legal involuntary hospitalization. However, I believe that in some states  a person can sign themselves in to a hospital  and be considered to be “committed” and can be held against their will for a certain period of time even if they change their mind and wish to leave. If a person is held in a mental hospital against their will but then is released by a judge  or by another or more senior doctor after the circumstances are clarified, is that person considered to be committed?

What about a person who voluntarily  enters a mental hospital to be treated for a mental condition completly unrelated to any potential violence. For example hospitalization for anorexia, incapacitating obsessive compulsive disorder, addiction to pain medication prescribed by doctors etc. In fact if the condition was such that the person couldn’t care for themselves, they might have even been admitted on an involuntary basis (“ committed “).

State Laws Concerning Mental Illness and Right to Own a Gun

Now I wondered about the wording of the various state laws. I went to the NCSL-National Conference of State Legislatures  website . All I can say is that it is quite a mixed bag on this subject. My state of California says the following :

A person is barred from possessing, purchasing, receiving, attempting to purchase or receive, or having control or custody of any firearms if the person:

• Has been admitted to a facility and is receiving in-patient treatment for a mental illness and the attending mental health professional opines that the patient is a danger to self or others. This prohibition applies even if the person has consented to the treatment, although the prohibition ends as soon as the patient is discharged from the facility;
• Has been adjudicated to be a danger to others as a result of a mental disorder or mental illness or has been adjudicated to be a mentally disordered sex offender. This prohibition does not apply, however, if the court of adjudication issues, upon the individual’s release from treatment or at a later date, a certificate stating that the person may possess a firearm without endangering others;
• Has been found not guilty by reason of insanity of enumerated violent felonies. A person who is found not guilty by reason of insanity of other crimes is barred from possessing firearms unless a court finds that the person has recovered his or her sanity;
• Has been found mentally incompetent to stand trial, unless there is a subsequent finding that the person has become competent;
• Is currently under a court-ordered conservatorship because he or she is gravely disabled as a result of a mental disorder or impaired by chronic alcoholism

Oklahoma law briefly  states : Oklahoma prohibits knowingly transferring a firearm to:

• A mentally or emotionally unbalanced person.

Texas goes into a great deal of detail :

A person is ineligible for a license to carry a concealed weapon if the person:
(1)  has been diagnosed by a licensed physician as suffering from a psychiatric disorder or condition that causes or is likely to cause substantial impairment in judgment, mood, perception, impulse control, or intellectual ability;
(2)  suffers from a psychiatric disorder or condition described by Subdivision (1) that: (A) is in remission but is reasonably likely to redevelop at a future time; or (B) requires continuous medical treatment to avoid redevelopment;
(3)  has been diagnosed by a licensed physician, determined by a review board or similar authority, or declared by a court to be incompetent to manage the person’s own affairs; or
(4)  has entered in a criminal proceeding a plea of not guilty by reason of insanity.

The following constitutes evidence that a person has a psychiatric disorder or condition described by section (1), above:
(1)  involuntary psychiatric hospitalization;
(2)  psychiatric hospitalization;
(3)  inpatient or residential substance abuse treatment in the preceding five-year period;
(4)  diagnosis in the preceding five-year period by a licensed physician that the person is dependent on alcohol, a controlled substance, or a similar substance; or
(5)  diagnosis at any time by a licensed physician that the person suffers or has suffered from a psychiatric disorder or condition consisting of or relating to:
(A)  schizophrenia or delusional disorder;
(B)  bipolar disorder;
(C)  chronic dementia, whether caused by illness, brain defect, or brain injury;
(D)  dissociative identity disorder;
(E)  intermittent explosive disorder; or
(F)  antisocial personality disorder.

The other states vary greatly. Take a look at that link .

Of course the big question might be how is this information determined.

Hospital Records, Gigantic Database or Honor System?

Will the information used to prevent someone from getting a gun permit  come off of insurance records, Medicaid, Medicare forms etc? Will there be a gigantic database of all mental health treatment? Or will this just be the honor system of the person applying for a gun permit? What will happen if someone reports to the  government that they know so and so was treated for a mental condition by such and such doctor or hospital and shouldn’t have a  gun permit? Will mental health professionals  have to release their records or  have to testify about their non- hospital treatment? Will there be any obligation if  a therapist learns in the course of therapy that a patient is applying for a gun permit but actually doesn’t meet the criteria of the state or perhaps of  some new all encompassing federal law??

Let’s Have a Dialog About This Subject

Now is the time for mental health professionals to join in the dialog that this country is going through. Let’ start it here. There are about 15,000 viewers /week on this blog according to the statistics which I get from word press but you are usually exceedingly reticent to send in comments. Perhaps this subject can be the exception. It may be very helpful to mental health professionals and patients if we participate in this national discussion. Please click on the comments button and let’s hear your thoughts on this subject. What should the law be concerning mental illness and the right to own a gun and how should such a law be worded? I also encourage readers outside the United States give us your viewpoint.

ADDENDUM: I was very pleased to see a recent letter by Dilip Jeste, M.D.President of the American Psychiatric Association which makes some very important points on this subject. Click here for the link

I am writing this blog one day after the horrific massacre at a school in Newtown, Connecticut. Thus far it is known that a 24 year old man shot and killed his mother and then took three weapons including automatic assault rifle, dressed in combat gear and  appeared at the school where his mother taught. He was recognized as the son of a teacher and was buzzed in. He then killed 4 adults including the principle who had recently  instigated stricter security measures at the school and 20 students between the ages of 6 and 10 as well as himself. There was one report that he had some kind of argument at the school the day before the shooting. There are also descriptions that he was a troubled kid in school who had no friends and was very shy. He was said to be very bright in math. It was suggested that  he may have had Asperger’s Syndrome and was on the Autism Spectrum. Another report said that he spoke of demons and therefore suggesting he may have been paranoid with schizophrenia. His parents were divorced after 17 years of marriage and his mother was reported as very protective. He has a brother at college.

I have no idea of his diagnosis and would not make any attempt to speculate on on the nature of his mental condition.

Psychological Trauma 

Common wisdom and research in this area tell us  that the closer a person is to the traumatic event,  the more likely and the more severe the psychological trauma will be. This however is a complicated issue. Certainly the adults and children who witnessed the shooting (including of course anyone wounded ) would be directly effected.  This would include anyone in the school  who heard sounds and participated in the terror of hiding and escaping from danger.

The two conditions that will emerge from such an incident  are  Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder(PTSD) . According to the Diagnostic Manual of the American Psychiatric Association (DSM IV), the necessary requirement for both of these conditions must include the following :

The person has been exposed to a traumatic event in which both of the following were present.

1-The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.

2- The person’s response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behavior.)

In addition for us to make a diagnosis of ASD there needs to be three or more  symptoms such as  numbing, detachment, absence of emotional responsiveness or reduction in awareness of his or her surroundings (being in a daze) or derealization ( things don’t seem real) or depersonalization ( you don’t feel like yourself) , a tendency to re-experience the event by flashbacks, an avoidance phenomena related to recollection of the traumatic event, impairment of social and other areas of functioning, increased  anxiety and arousal with sleep and concentration problems and a duration of these symptoms  2 to 4 weeks.

In order for us to make diagnosis of PTSD  there needs to be similar symptoms as ASD with one or more symptoms of recurrent and intrusive recollections (manifested in young children by repetitive play), recurrent dreams, re-experiencing the traumatic event with illusions , hallucinations and flashbacks , physiological reactions, , persistent avoidance of stimuli associated with the trauma, numbing , efforts to avoid thoughts and feelings related to trauma, decreased interest or estrangement, inability to have loving feelings, insomnia, outbursts of anger , exaggerated startle response  impairment in social functions, with a t least one of these symptoms lasting more than one month.

For more detailed and exact definitions see the DSM IV (or the new DSM V which may be somewhat revised )

Trauma Not Limited to Immediate Geographic  Area

The development of these symptoms is not limited to people in the immediate vicinity.

Classmates who didn’t attend school that day can have symptoms as can people all over the world who are traumatized by accounts in the media which vividly reconstruct the events and allow others to identify with the victims. There will be very few school age children in the U.S. who will not have heard about the details of this event

I recall at the time of the Challenger disaster, we saw school children all over the country effected by seeing this spacecraft carrying the astronauts and some teachers disintegrate before their eyes on television . Similar situations have happened in other tragedies, which are covered, on TV.

Long Term Effects

It should be recognized that the acute and  long term psychological  effects of this trauma  goes beyond the two disorders described above The experience also  becomes woven in the psychological makeup of people who are impacted by it whether near or far where it happened . For some, the innocence of childhood is taken away . The sense of security is changed forever. Long after the acute symptoms are gone, the effects of this event will have changed the individuals who experienced it. In some cases it will be a determining factor in how they will mold their future lives. Perhaps they will always be a cautious person, looking for unexpected danger. In other ways, the trauma can motivate persons to become doctors, nurses, police, researchers or influence the way they view their own lives for better or worse.

The Need for Immediate Psychological Intervention;

There has immediately been an outpouring of offers of psychological help.

I am sure the school system ,local and state agencies  will bring in counselors and therapists. Local mental health professionals  will ofter their help. I know the Committee on Disasters of the American Psychiatric Association ( of which I have been a member ) has offered the local Psychiatric Society materials and information that can be useful . There has been offers from International Groups that have experience  with these situations as well as from the Red Cross and from the nearby Yale Child Study Group. There will be individual and group meeting with the teachers and counselors as well with parents and of course with the children. The teachers will be trained how to be sensitive to the reactions of the children. It is important that all involved be aware of the various symptoms that can develop after events like this (some of which were described above) Danger signals need to be picked up. I am sure a wide variety of techniques will be used for one to one therapy  as well as in groups. Talking in groups can be useful for many but for others individual sessions can be very helpful  or a combination can  be used. For some of the children, the comfort of discussions and interactions with their parents will be  most important. Some parents will know how to handle this, other parents will benefit by discussion or counseling. I don’t believe there is one method which needs to be applied. The techniques used in individual and group treatment can cover a wide range from catharsis which involves expressing  one’s experience and feelings, Cognitive Behaviors Therapy ( CBT) which uses correcting misconceptions  and directly dealing with ideas and behavior and  psychodynamic therapy  where underlying meaning is explored and interpreted. In some acute situations medication (anti-anxiety or other stronger tranquilizers  can be used and when conditions  such as major depression is identified, antidepressants may be prescribed.  Other techniques and combinations of approaches will be used especially the human support and caring offered by people near and far and by such groups as the Red Cross which will be quite useful and meaningful.

Grieving the Loss of Life.

As most of us know grieving is a very intense process. Kubler-Ross described five stages of grief ; denial,, bargaining , anger , depression and acceptance. However, when there is unexpected death, traumatic death especially by murder and death of children, the grief takes on a different pattern which has been labeled Complicated Grief. We can expect the anger and depression to be greatly intensified and the duration of the intense emotions to be much more prolonged especially when there is the loss of a young child. Ultimately various types of memorials to the lost child which can give significances to the lost out life can be helpful

Concern About Other Disturbed Individuals Including Copycat Incidents

It is only natural that there will be concern on all levels that disturbed individuals who might do anything like this incident should be identified , receive help and be safely  in a place where they can not harm anyone. This problem is accentuated at the time of such an incident and in the immediate aftermath since we know that sometimes in the mind of a severely mentally disturbed person, media reports of this event have  the possibility of precipitating a copycat pattern of behavior in another disturbed person. The presence of mental illness is usually identified by family , friends and teachers at an relative early point in life. While there has been great progress in providing mental health care in the United States since the 1960s , there are still people who do not get the care that they need because of finances and the unavailability of services. Quality health care should be available to everyone and this includes those with mental illness.

The Overwhelming Majority of People with Mental Illness are Not Dangerous

Only a very small percentage of people with mental illness are a serious danger to other people. An incident such as this school shooting invariably unfairly intensifies the stigma towards people with mental illness. This can hinder recovery and adaptation to this condition. We need continued research in identifying people who could be dangerous and we also need to understand and educate the public about mental illness.

The Gun Control Issue and The Psychological Implications.

We don’t yet know the history and the story why the Connecticut shooter’s mother   had registered guns in the house. I would guess that most probably if there were not these guns in the house ( which included automatic weapons ) that untold psychological trauma would not have occurred. The young man may have done something terrible but if guns were not available to him, the   chances are,  not as many people would have been killed.

I also wonder about the psychological effect of his growing up in a household where such guns were owned , kept and valued. I understand the argument that most gun owners may teach their children about gun safety. However when there are guns present, there may very well be the underlying message to a disturbed child, that when you are angry this is the way that you can act.

**** Silver Linings Playbook-

We are always sensitive when there is humor presented at the expense of people with mental illness. This is what seemed to be the case when at the beginning of the film we meet Pat (Bradley Cooper ) who is about to be released from a mental hospital. He is being picked up by his mom (Jacki Weaver) and we see that he has Bipolar Disorder, flies off the handle very easily and fools the nurse into thinking that takes his medication when he really cheeks it and throws it away. The humor continues as we meet his father, Pat Sr. (Robert DiNiro) who has an obsessive disorder and is a superstitious gambler who always bets on the  Philadelphia Eagles. From finding ourselves unhappy that we are laughing at these dysfunctional characters, we then become aware of the great pain that they are suffering which early on shows in the sensitive performances of Weaver and DeNiro. The storyline then reveals the circumstances of Pat Jr’s hospitalization and his trauma in regard to his wife’s behavior. Bradley ‘s performance is tremendous as he plays mentally disturbed , determined and very smart. However the real stand out and maybe even Oscar performance is by Jennifer Lawrence who plays Tiffany a beautiful. dysfunctional , quirky , vulnerable and very intense woman. She is  recently widowed, who becomes entwined with Pat as he is trying find a way to recapture his wife. The photography, mostly single camera  fast moving as is the directing by David O. Russell, the editing by Jay Cassidy and the music by Danny Elfman which includes Frank Sinatra and Johnny Mathis at the appropriate times with a little “ dancing with the stars”  thrown in. In the end what makes this movie a winner is that it  is a real love story, complete with sentimentality all around. Think Frank Capra and It’s a Wonderful Life, Christmas lights and all. (2012)

In a recent article in Psychiatric Times Dr. Tondo and Baldessarini  noted that 90% of suicides occur in persons with a clinically diagnosable psychiatric disorder. Patients with Major Depression or Bipolar Depression have a 20-26 fold increase of mortality rate over the general population. It was also stated in this article the fact than fewer than 1/3 of persons who commit suicide are receiving psychiatric treatment at the time of their deaths. The authors further state that there is only inconsistent evidence that antidepressants may help prevent suicides.

It was thought that the strong association between the rapidly expanding use of antidepressants and the moderately declining suicide rate in the US and in other countries were indirect evidence of effectiveness of antidepressants in reducing suicide.

Several recent studies have shown that mood disorders have been associated with increased suicidal behavior. This is especially true in patients with a mixed, manic-depressive, or dysphoric-agitated state, and perhaps also in those with anger, aggression, or impulsivity—all of which are particularly prevalent in Bipolar Disorder and may contribute to the unusually high suicide risk in persons with this disorder. In patients with such conditions (especially young patients), antidepressants may lack a beneficial effect or even increase suicide risk, at least early in treatment. Long-term treatment with mood stabilizers, particularly lithium, may be a more effective component of comprehensive clinical management aimed at suicide prevention.

From clinical experience we know that psychological conflict, psychological trauma, grieving, interpersonal conflict and other psychological issues can all contribute to self destructive behavior which can result in suicidal behavior. Suicidal gestures which may have been initiated to get attention or manipulate others can inadvertently result in a completed suicide. There are special issues concerning suicidal behavior in the military where recent studies have shown more soldiers are killed by suicide than in combat. There are special issues concerning suicidal behavior in children and adolescents. Bullying behavior including cyber bulling has been shown to induce suicidal behavior in young people.

Suicidal behavior can be quite complex as well deadly. It should go without saying that psychotherapy is usually necessary in treating patients who have suicidal ideation or who have demonstrated such tendencies or actions. Frequently, it may be combined with medication and sometimes it is the treatment of choice without medication.

Suicide prevention is a challenging issue not only for mental health professionals but for leaders in the military, teachers, parents and for us all. We also need to recognize that there are many mental health issues that have to be faced in the aftermath of a suicide.

We shall try to discuss many of these issues in future blogs. I am also pleased to announce that suicide will be a major part of the theme of the May 16-18 meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry (of which I am the current President) which will be held in San Francisco (just prior to the meeting of the American Psychiatric Association in the same city). A very interesting and informative program with outstanding speakers is being developed and will be announced shortly. I will also provide further information about this program in future blogs and you can contact me  if you have any questions at this time

After over fifty years of treating patients, my father, a psychiatrist, took down his shingle this week. He picked a day to stop practicing, saw his last few patients, stepped out of his office, closed the door and walked away. In the end, after thousands of forty-five minute sessions of talking, listening and helping, ironically, he said only, “it’s time to stop”. He was leaving behind a lifetime.

He was not turning back, but neither was he turning his back. Not on a half century of patients and their stories. Stories of sadness and of joy. Of wishes and fears. Misery and hope. Suffering and triumph. Bitter stories and sweet ones. Stories of despair and of fulfillment. Of accommodation and rebellion. Freedom and constraint. War stories and stories about making peace. Angry stories, guilty stories, lonely stories, and love stories. But mostly, stories about all the conflict and beauty in between. The stories of our lives.

How does one walk away from the relationships with patients? Patients with whom one has spent years together at sea. Straining, struggling, and delighting in intangible moments of connection that seem to hold much of the meaningfulness? How does one walk away from being immersed, day after day, year after year, in the winding and jagged paths, the various and sorted twists and turns of lives lived. And all of the sorrow, satisfaction, envy, frustration, pride, shame, angst, gratification, regret, and pleasure that comes with. Most of all, how does one walk away from the sheer privilege of sitting down with another human being, and together, trying to untangle it all.

We never know in this work, when a patient walks through the door for the first time, if this will be the one and only session we will have together, or if it will mark the beginning of a relationship that will span a good chunk of a century. Will they be here and gone in a relative instant, or will this person sitting with me today, a stranger, be a person I will come to know in some ways better than my own children and with whom I will grow old together.

One of the patients my father said goodbye to this week has been a patient of his continuously since 1965. When this patient walked in the door of my father’s office for the first time, Lyndon Johnson was president. The US troops were not yet on the ground in Vietnam. The patient, at the time, was in his twenties. He is now in his seventies, a grandfather.

How does the patient walk away from my father? A patient with such bad anxiety that it flirts with psychosis. He is often frightened and is delusional at times. For forty-seven years he has sought relief in my father. He trusts him. He is calmed by him. For the patient, what my father does is “magic”. Sometimes it helps to have magical thinking.

How does one even give up a decades old office phone number? A phone number that has traveled with my father to all of his many offices over the years. A number that I have known since I am a child. In the era before e-mail, websites and texting, it was through that one phone number that a career’s worth of patients reached my father. Originally on rotary phones, dialing it up in times of need, times of crisis, times of everything. It was through that number that my father put food on the table and as patients like to say, “sent his kids to college”. And it was through that number that all of the relationships, over all the years, began. The phone number was, in many ways, a lifeline.

So how does it all come to an end? How does the shingle, dripping with history and still pulsing with life, get put away? Not so easily. Not so fast.

As for the phone number? My father is now having the line installed in his home. He told me, “You never know when someone might want to call”. It strikes me that he is not installing the phone number at his home, but where he lives. He is staying connected. To who he is. To others. To being alive.

As for the patient, what will happen to him? Just as my father was reluctant to leave his patient, the patient, as one might imagine, was reluctant to leave him. As it turns out, my father will transfer the care of his patient to me, and he will now become my patient. Just before the termination of their relationship, after all the years, my father offered some final parting words of comfort to the patient he has known the longest, and with whom he has spent a lifetime. He said, with a knowing smile, “Don’t worry, my son has the magic too”. The words were comforting. To all three of us.

The next generation of talking and listening will carry on. Going forward, there will be more winding and jagged paths, more twists and turns, and more stories to tell, all told, as we move further, along an unbroken chain.

We live within each other. Within each other we live on.

Mark Singer
September 2012

Mark Singer,M.D. is an Assistant Professor of Psychiatry at New York Medical College and has a private practice in New York City and in Valhalla, NY. His email address is marksingermd@gmail.com
Paul Singer,M.D. is Professor Emeritus of Psychiatry at New York Medical College.

Let us look at typical situation where a person comes to a psychiatrist for evaluation because of depression. The most common sources of this referral would probably be from one of the following (or a combination )

1- Primary care physician refers the patient
2- A non psychiatrist mental health professional who is treating the patient in psychotherapy refers the patient for medication
3- The patient is self referred either finding the psychiatrist at the recommendation of an acquaintance or the patient finds the psychiatrist through the Internet

The referral might be influenced by finances and by insurance considerations. The patient may be going to a low cost clinic or they may need to find a psychiatrist who is on a particular insurance panel although insurance companies will often allow their subscribers to see an “ out of network” doctor and will cover part of the fee. Many private psychiatrists have either opted out of the Medicare program or are not accepting Medicare patient so this will also have to be determined before choosing the psychiatrist.

The patient calls the psychiatrist and makes the appointment. The initial appointment is usually 45 minutes – 1 hour. It is perfectly appropriate to discuss the fee and any questions about insurance coverage on the phone

THE INITIAL PRESENTATION

The psychiatrist would take a careful history and look at the reason that the patient is coming ( in this case depression ) and examine the development of this symptom and circumstances around it. Similarly the presence of any other symptoms, problems or difficulties would be carefully examined.

After looking at any of the issues which the patient brings up, the psychiatrist would ask about many other symptoms which may not have been mentioned by the patient such as anxiety, phobias, obsessions and compulsions, sleeping difficulties, appetite or eating difficulties, sexual problems, paranoid thoughts, auditory and visual hallucinations, suicidal thoughts and actions, anger, irritability, racing thoughts, grandiose feelings, short term and long term memory problems, confusion, tiredness, excess energy, dreams, nightmares and a bunch of other things. There would be questions about a history of traumatic events, recent loss and grieving as well as any history of substance abuse including alcohol. The psychiatrist would ask about a history of previous treatment for mental disorders and any psychiatric hospitalization. There also would be a review of any family history of psychiatric disorders. Also, not necessarily in this order the psychiatrist would learn about the patient’s interpersonal relationships with the people in his or her life. This would include getting some preliminary understanding of the patient’s childhood and relationship with close family members. It would also be important for the psychiatrist to understand about the existence of any medical problems, previous medical treatment as well as any medication that the patient may be taking .

WHAT CAN THE PSYCHIATRIST CONCLUDE?

Most of the time at the conclusion of the first interview the psychiatrist will have at least a tentative diagnosis related to the depression and any other condition that the patient may have. It may be that the psychiatrist feels that some medical tests are in order such as a test for low thyroid functioning which can cause depression. The psychiatrist may want the patient to have a neurological consultation or even some brain imaging to rule out something like a brain tumor although that would be quite rare. The results of a physical exam and lab tests may be useful in making the diagnosis and in determining which medication can be utilized if that is being recommended. Most of the time a tentative diagnosis and a recommended treatment plan can be instituted before all the results of any requested medical consultation or tests are received.

For the this discussion, let us assume that the patient doesn’t have any other major psychiatric disorder other than a major depression. There is no substance abuse use, schizophrenia or bipolar disorder or underlying medical problems. Let us also assume that at the time of the consultation the patient does not require hospitalization for suicidal or other dangerous behavior including needing treatment for substance abuse. If the patient was having a first major depressive episode or if it were a repeat episode it would mean that he or she were having significantly depressed mood with possible problems in sleep, appetite, concentration as well as diminished interest and pleasure . The patient may be feeling worthless, guilty and having thoughts about death and suicide even if they didn’t have an active plan to kill themselves. There are other symptoms also and they all don’t have to be present. Most likely the patient isn’t functioning well socially or at work . Even if most of these symptoms are not full blown, it has the potential to get worst and the fact that patient has sought out help indicates that he or she is having a difficult time.

ANTIDEPRESSANT MEDICATION

Anti-depressant medication may well be the treatment of choice to alleviate many of these symptoms. It is most likely going to take at least 4 weeks to get a significant improvement if this medication is going to work.
The dosage may have to be adjusted and the patient will have to be monitored for side effects and possible worsening of symptoms including the potential of becoming a serious suicidal threat. In some situations more than one medication may need to be utilized.

PSYCHOLOGICAL FACTORS

Thus far we haven’t factored in how important are the psychological factors in the patient’s life. Self image, personality, realistic issues in the environment, interpersonal conflicts, failure to achieve goals in school, work and in love can all be an important part of the equation. While improvement in the patient’s mood may very well occur with medication, this is no guarantee that these other issues will improve. Therefore psychotherapy should be considered as the main treatment recommendation. It is true that when a depressed mood lifts, a person is often better able to deal with certain problems. But on the other hand a antidepressant is not going to change deep seated neurotic symptoms, self image and serious relationship problems.

COMBINATION OF MEDICATION AND PSYCHOTHERAPY

Even objectively looking at basic depressive symptoms there is a lot of research that shows that some form of psychotherapy with medication is better that either one of these modalities when the problem is depression.

Of course the recommendation for treatment will also have to take into account, the age of the patient, life circumstances, social supports etc. However in most cases a combination of psychotherapy and medication is often the treatment of choice in the above situation. In cases of a recurrent depression, it may be that the person has previously had psychotherapy and a reinstitution of medication is all that is required or that the patient has done well on medication alone in the past.

WHO DOES WHAT ?

Many psychiatrists such as myself do psychotherapy and also can prescribe medication. Ideally many prefer to do both with a patient when it is indicated. Some psychiatrists only do psychopharmacology and would refer the patient to someone who does psychotherapy. If a patient is referred to a psychiatrist by a non-psychiatrist therapist, then the psychiatrist would prescribe the medication and the original therapist would usually continue the psychotherapy. This requires collaborative therapy in which the patient gives permission for communication as needed between the two health professionals. The psychiatrist would have to decide on the frequency of follow-up visits to adjust medication which can usually be done in time limited visits and the two professionals may have to talk periodically to decide if the treatment needs further adjustment. On some occasions, the psychiatrist may feel that the depression does not or may not require medication but rather there should be a trial of therapy first. This means that if there is a non psychiatrist therapist who referred the patient to the psychiatrist, that person would have to be comfortable in continuing the therapy without medication. Medication could always be reconsidered at a later date.

Another variation would be a trial of medication perhaps with continued psychotherapy and then perhaps a trial off the medication as the psychotherapy continues. Sometimes a non-psychiatrist physician will be comfortable in prescribing medication but might periodically want a to consult with a psychiatrist who would see the patient for an occasional visit.

NO SIMPLE ANSWER

It would be nice if there were a simple blood test or MRI to determine the best form of treatment or even a simple test to determine whether psychotherapy will be successful. While psychopharmacology and psychotherapy techniques have come a long way in the past 50 years, there still needs to be good clinical judgment and a working alliance between the patient and any professionals working with them.

Comments are welcome from both mental health professionals as well as patients, potential patients and anyone else.

Public Awareness About the Connection Between Depression and Physical Health: Specifically Heart Disease

Michael Blumenfield, Julianne K. Suojanen, Charlene Weiss

Abstract

The medical community continues to acknowledge a connection between depression and physical health, for example, cardiac disease. This study addresses public awareness about depression’s effects on physical health, the relationship between cardiac disease and depression, and preferred sources of health information, in an effort to inform future health education programs. A survey, administered to 816 adults ages 40-69, focused on public awareness, perception of depression as an illness, its impact on other illnesses such as heart disease, and sources of health information. (1) Eighty-three percent (83%) of respondents felt depression was an illness; (2) a slightly higher percentage (85.8%) felt a mental disorder, like depression, could affect the course of a physical illness; (3) respondents’ awareness of links between depression and cardiac disease ranged from 29.8% (awareness of depression as a risk factor for coronary artery disease) to 31.6% (awareness that depression can increase the risk of having a second heart attack); (4) print media were the most frequently cited sources of health information (22.7%); and (5) more highly educated respondents were more informed about depression than respondents with less education. Although a majority of respondents (1) recognized depression as an illness (2) thought it could complicate recovery from a physical illness, less than a third of them were aware of links between cardiac disease and depression. Demographic groups differed in their preferred sources of health information, especially across educational levels, demonstrating a need for targeted health educational outreach in efforts to reach a variety of populations.