Violence in College and University settings

Three separate examples of violence in college and university settings in Connecticut may have us wondering whether rates of violence have increased in recent years (http://www.wtnh.com/dpp/news/middlesex_cty/college_campus_safety_questioned). We certainly do hear a lot from the media about those events, which raise awareness that our campuses are not as secure as we would like to think. Somehow we think that if a young adult is a college student they are protected from the various factors that put youth of college age at risk. I suspect they are to some degree, violent homicides are probably much less frequent in those attending colleges and universities. See the American Psychiatric Nurses Association website (APNA) for a review of literature on workplace violence that includes data from colleges: http://www.apna.org/i4a/pages/index.cfm?pageid=3786.


These may be the only 3 homicides in CT Colleges this year, but think of all the homicides we have heard reported in the news (and many of them have gained much less coverage by the press). We should remember that homicide is a leading cause of death in this age group as a whole. Here is a table showing that data, which of course shows those 15 to 24yrs having the highest homicide rates:
Data Source: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf; & National V ital Statistics Report, V ol. 47, No. 9, November 10, 1998


This data does not suggest an upward trend. The rates actually look pretty stable (possibly lower than in 1996, actually).

Here is a table showing us some of the leading causes of death that include 15 to 24yr olds:

Data Source: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf

As you can see Accidents are #1, Homicide is #2, and #3 is Suicide. (I wonder if this year's H1N1 will even cause a little blip here?) This data suggests that we should be far more concerned about accidents or accidental injury or death in this age group. Below is a chart showing the ranked causes of death in those age 20-24yrs (considered the college-age population, but does not mean it includes only college students). These 3 causes account for 70% of all deaths in this age group.

Data Source: http://www.statisticstop10.com/Causes_of_Death_College_Age_Adults.html;
National Center for Health Statistics, National Vital Statistics Reports March 7, 2005

We are wise to be concerned about homicide and violent behavior in this age group (it is certainly of concern given that it is the 2nd ranked cause of death). What are some of the reasons that our society is violent? I think there are many, here are some off the top of my head (sorry no data to support, just things I remember from various studies, or my ‘opinions’ which may not have supporting data!)
· Violence in the media (right back at you media for sensationalizing tragedies such as these in CT this year) including the news (and streaming news), movies, videos, and most recently: Reality TV!
· What about video games? I have seen data that suggests videos games where we actually shoot at others does increase our comfort level with shooting real human beings…. I believe the military actually researched this as a method for helping regular people like you and I to get over our inhibition about shooting a human being.
· Firearm availability (a very interesting thing to look at is how rates of these causes of death vary by availability); also interesting is how in regions of the country areas with high rates of homicide tend to have ‘lower’ rates of suicide and vice versa (see the reference for Death, Final Rates 2006: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf)
· Incivility and bullying in our world, at work, at school, at the grocery store… oh yes and what about our impatience and lack of understanding of others...

What would you hypothesize are reasons for the high rate of violence in our society?

Is there a breaking point for business? There certainly is for workers…

In the past two decades workers have constantly been pushed to do more with fewer resources and now it seems all too commonly for less pay. While many have lost their jobs, others have experienced pay cuts and demotions while companies attempt to balance their books in a bad economy. My question is whether there is a breaking point. At what point do businesses stop making corrections, realizing that the immediate cuts to change the cost of doing business are actually hurting the bottom line?

An example of some of the stresses experienced by workers is provided in the NYT article about a pilot whose wages were cut in half when he was forced into a lower position with his airline. This is far better than being out of a job, however this results in a variety of negative ramifications to the worker and his well being. Here is a link to the article: http://www.nytimes.com/2009/10/14/business/economy/14income.html?th=&adxnnl=1&emc=th&adxnnlx=1255521777-AqOMsLK3sCDCBUfOCqSfzA

The effects of such a change include: the demeaning aspects of being demoted (even if to save the job); anger (related to being demoted for no reason, having to work the same hours and probably similar tasks, loss of status); irritability and ‘flying off the handle’; constant worry about meeting financial responsibilities; working more than one job to make up for the loss; among a variety of other things. The work-family interface takes a hit as well, with all family members experiencing greater pressure and need to adapt to this external stressor.

Several other employers are cited in the article as following the same path, either cutting pay or decreasing employee work hours. The Bureau of Labor Statistics indicates that weekly pay of production workers (80% of US jobs) has decreased for the past 9 months. This decline is similar only to declines from the Great Depression.

Another form of pay cut is to increase workload for a job, which has also become increasingly common. Of course this change is not measurable in weekly pay of workers. I’m not aware of any systems to collect this information. This is an all too common experience: not filling open positions or cutting or laying off workers and redistributing work among those left behind. This experience is perhaps measured partly in scales of psychological demand, although I do not think that this is a precise measure of the practice. We do know that psychological demand, a common workplace stressor, has negative health effects, including increasing risk of depression and cardiovascular disease. I suspect in some types of work the risk of employee injury increases as well.

Another problem with the practice is that individuals often are afraid to speak up about these negative changes for fear they will be let go. Individuals tend to meet the increased needs they face, in an effort to help out, and to be perceived as someone willing to pitch in at the time of crisis. The problem is that the crisis never ends. How long do employees continue to work with increased demands or reduced pay or hours? That is the question…

I’ll have to look and see if the Bureau of Labor Statistics keeps any data on this problem, which is perhaps new, but all too common in our current economic reality.

Chronic Fatigue Syndrome: Hopes Raised with Discovery of Virus

Chronic fatigue is an interesting clinical syndrome that quite often gets an individual either referred to psychiatry or diagnosed with psychiatric problems. It has stumped clinicians in terms of effective treatments.

The current study discussed in the article below, has identified a retrovirus that was present in 67% of those with Chronic fatigue vs. 3% in the general population. This is promising, but not quite as sensitive or specific as one would wish.

This syndrome is a good example of how health care providers often marginalize conditions that they are not able to identify and manage well. Some of this results from the desire or expectation (unrealistic usually) that our health providers will identify, manage and alleviate our health problems. A result of this projection is the provider often feels a failure for not being able to cure problems that still have not had adequate study. Then I think the marginalization happens, and often the problem gets labeled a ‘psychiatric or mental health’ issue. When this happens it is as if the world is then saying it is all in your head. As if you are making it up! What a crime!

I have known many people with Chronic Fatigue who were quite well balanced and without psychiatric symptoms of any kind until this syndrome literally ‘took over’ their lives. I have also worked with patients referred to psych as a last ditch effort to ‘fix this person’. Unfortunately we cannot ‘fix’ those with this syndrome. I am certain that psychotherapy (and some pharmacologic agents) can be helpful to those coping with this problem. But I do not see it as that different than coping with many chronic diseases.

Perhaps health care providers need to be more comfortable with what we have not yet learned. If we owned up to what we were not certain of, the expectations of those we serve would also be lowered. Perhaps then those with real health problems would not be 'banished' to psychiatry.

Hopefully this study is a true step forward in our learning more about Chronic Fatigue Syndrome.

http://www.nytimes.com/2009/10/13/health/13fatigue.html?pagewanted=1&_r=1&th&emc=th

More on SSRI’s and congenital malformations...

A new study is available that examined nearly a half million children born in Denmark (oh, the beauty of having readily available data!) between 1996 and 2003 finds a higher risk of septal heart defects (OR 1.99, 95% CI: 1.13 to 3.53) in those filling prescriptions for SSRI’s overall. Here is a link to the study:
http://www.bmj.com/cgi/reprint/339/sep23_1/b3569 Pedersen, L.H., et al. (2009). Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: population based cohort study. BMJ, 339(231).

This looks like a study that was carefully carried out, and it does provide further data that there are risks to the child from the mother’s treatment with an antidepressant drug early in pregnancy. I have mentioned in prior posts my concerns about use of psychotropic drugs during pregnancy (here is the link to my prior blog posting:
http://blogs.yale.edu/roller/page/mentalnotes?entry=psychotropic_drugs_during_pregnancy) The prior studies seem to show that there was greater risk of problems with using fluoxetine and paroxetine (which led to warnings issued). Particularly at risk were women using SSRI’s in early pregnancy, who also smoke. This of course is quite applicable to most of the women we treat in mental health settings. It is a good reminder to discuss the risk with women as well as discuss and plan appropriately if the woman is planning a pregnancy.

This study found greater risk of septal defects with use of sertraline (3.25 times the risk) and citalopram (2.52 times the risk). Added info offered with this study is that risk of heart defects were even greater in those using more than one type of SSRI (overall risk of heart malformations OR: 3.42, 95% CI: 1.4-8.3; and risk of septal defects OR: 4.7, 95% CI: 1.7-12.7). That also suggests that in younger women we carefully examine our polypharmacy practices (yes, I have a prior post on that as well… http://blogs.yale.edu/roller/page/mentalnotes/20081208) and won't get into that now.

This study is a good example of how difficult it really is to know harmful effects of treatments. There is a need for large population based studies to answer questions like this. The authors of this study (which evaluated a half million liveborn children from 1996 to 2003) suggest that studies be carried out in larger populations to determine the true risk (as # of exposed children was n=1370 of the half million studied). (i.e. if untoward events occur at a very low rate(say < 1 in 10,000), then the n exposed (n=1370) may not be large enough to expect to get even one occurrence)

I don't think we can afford to take lightly the risk of medications during pregnancy. A careful and well thought out plan for how to protect both Mother and baby is important.

I wonder if the prevalence of antidepressant use in pregnant women is higher in the US?

Sports and Risks of concussion

A new study has found much higher rates of dementia in retired NFL players. Here is the link to the NY Times report on it: http://www.nytimes.com/2009/09/30/sports/football/30dementia.html?_r=1&th&emc=th
Evidence has been accumulating on this issue for several years, it will be interesting to see how it is handled by the NFL. Prior studies have also linked concussion to depression. This study was done by a pretty reputable group (Univ of Mich Institute for Social Research).

Of course this has implications for many children and adults who are injured in sports and other activities. I've heard from many school nurses who find that injuries on the field are being taken much more seriously than they had been previously.

Unfortunately I've also heard stories of children being knocked out (and not responsive) on the field who go back in to play after injury rather than going to be evaluated medically. It seems coaches, athletes, and parents need better education about the risks of 'playing through' an injury. Particularly given this new evidence.

The idea that football which already has a host of protective gear in use including helmets, has this problem is troublesome. How will we protect children and adult athletes from these injuries?

Evening event: Thursday Oct 1, 2009

We are hoping the word has gotten out to Psych APRN's in the area to join us for an evening of discussion related to the future of our profession (both Nationally and in CT) and networking. Hope to see you there!

LACE and the Advanced Practice Psychiatric Nurse (APRN)

There is a lot happening nationally in Advanced Practice Nursing. It is unsettling at times because it is unclear whether the voices of all Master’s prepared psych nurses are being heard. Given that whatever happens with LACE (which stands for Licensure, Accreditation, Certification and Education) recommendations will affect the ability of nurses to practice (and find work) in the future. I hate to think that a small group of nurses are chosen to decide the future of our profession without all members of the profession having input. This is an issue affecting our livelihoods and careers, and for this reason all the professionals involved should be represented.

The current proposal, approved by APNA (the American Psychiatric Nurses Association), involves APRN's in psych being considered a ‘population’ rather than a ‘role’. Examples of roles in Advanced Practice nursing are Nurse Midwife, Nurse Anesthetist, Nurse Practitioner, etc. Examples of populations, as currently defined are gender, pediatric, psychiatric/mental health (see the links below for further info). My view is that Psych-Mental Health APRN’s should be considered a role. Unfortunately this was decided by a small subgroup working on the model, and to my knowledge did not involve input from all involved. There are several problems with this decision:
1. We should have autonomy in defining the future of Psych Advanced Practice Nursing. We remain tied to NP and CNS group regulation. This is despite our clear differences in focus and role. These other groups do not understand or know what the Psych APRN role is, yet they define competencies and other standards that guide education, practice and certification.
2. We are not able to define the specific aspects of role unique to psych that are not applicable to any other specialty group.
3. We remain stuck with two kinds of psych APRN’s: NP and CNS despite the fact that these roles have been shown to be nearly completely alike. This means we also have 2 kinds of certification again despite the redundancy in role.

The other aspect of the models being considered are that our educational programs must provide a lifespan approach to education. I think this is fine, however I think we may be taking this a step too far in relegating that in the future all Psych APRN’s will be Family Psych NP’s. While it is an interesting population level solution for providing care to children/adolescents in rural areas, I think it will produce a very generic graduate without much skill in any population (this is expected to require 200 clinical hours for each student in each population group: child, adult, geri). We are all very aware of the differences in skills required to treat children and adolescents vs. adults and elders. I do not think this is the best plan for the entire profession. Graduates will have little focused experience with psychotherapy and medication management in any population group. In addition, I rarely see clinicians or students entering our program who are interested in working with all population groups.

Finally, I would like to see that planning is in place for articulation of all Master’s prepared psych nurses with the new requirements. For example,
· What will current child or adult CNS’s and NP’s do? Will they be allowed to practice as a ‘Family Psych NP’?
· What will Master’s prepared psych nurses do who have completed their educational preparation but are not currently CNS or NP certified or licensed as an APRN? This happens due to family obligations, practicing in a clinical or work site where certification is not required, and in some states due to lack of definition of roles related to APRN billing or prescriptive authority.
· Who will teach the new ‘Family Psych NP’? As we change certification and educational requirements we have not been vigilant about articulation for those with the most experience who have actually developed psych Advanced Practice roles. Will Psych CNS’s remain eligible to teach in Psych NP programs? Will the Adult CNS or NP be able to teach the Family Psych NP student? We have a shortage not only of direct care providers but of nursing faculty as well. What plans are being made for role articulation from the many current levels nurses practice from now?

This is an issue affecting all of our livelihoods, I think the voices of psych APRN's need to be heard by our national leaders. We cannot accept a group of 7 or 12 individuals deciding the fate of an entire professional group. Not when it affects whether you or I will be able to practice and make a living. I encourage all Psych APRN’s to be vocal about this. In addition Psych RN’s should also be vocal. This is their future as well, they may decide to take the next steps and further their nursing education.

The other side of this is that we can’t afford to complain about the resulting plans if we haven’t taken the time to learn about the issues and told our representatives what our wishes are.

Here is a link to the APNA website where you can begin to see some of the plans that are being made. I’d love to hear your thoughts!
http://www.apna.org/i4a/pages/index.cfm?pageid=3498 (on LACE)
http://www.apna.org/i4a/pages/index.cfm?pageid=3707 (on APRN Consensus Model)
http://www.apna.org/i4a/pages/Index.cfm?pageID=3717 (presentation on options for Psych APRN’s

If any of you are going to be in or around New Haven, CT in the next week, our APNA Executive Director, Nick Croce will be part of an evening event where we will hear the latest on Psych APRN issues. Consider joining us for the evening!

Signs of suicide

I was reminded by the article written about Finn Casperson’s death, of the signs often present when a person is contemplating suicide (http://www.nytimes.com/2009/09/16/business/16suicide.html?_r=1&th&emc=th). A prominent businessman, Casperson resigned from several boards he worked on as well as put his property up for sale prior to ending his life. While the ‘news’ side of the story relates to speculation that he had hidden his money away to avoid taxes and might soon be caught, this potential which obviously might be very stressful, is second to the fact that he also had kidney cancer. It is unfortunate that this angle was chosen for the story. It appears this businessman and philanthropist will now be dragged down in the desire for a story.

There were some cues to suicide in this story that are good reminders for us: his resignation from several boards, stepping down from civic and private positions that it appears he found quite meaningful and important; and placing his estate up for sale. Those seem to be signals of a person withdrawing from his life. We know that often prior to ending their lives, individuals do try to put things in order and take care of things important to them. Of course in the context of treatment for kidney cancer, it might be perceived that these were a way to limit activity and focus on getting well.

It is always important that clinicians consider stressors as well as actions taken by individuals in trying to determine their safety. Mr. Casperson’s story shows us a good example of this often overlooked sign, which we do try to recognize in those we assess who are depressed or overwhelmed by many stressful events.

We often discuss how difficult it is to really be certain that your assessment of someone’s mental state is accurate. Newer students feel their lack of experience contributes to having a less definitive knowledge of whether someone ‘is safe’. The article does not indicate whether Mr. Casperson’s family, friends, or caregivers had any awareness of the potential for suicide.

Unfortunately Mr. Casperson’s story (at least as told here) is a reminder that there are times we will not know how deeply a person is suffering, and that if intent on ending their life, individuals are quite capable of keeping this hidden from those who know them best. My heart goes out to his family and friends who suffer now with his loss.

A step in the right direction for those with disabling mental health problems?

I think I am pleased to see the state of New York taking a stand to protect the rights of those needing continued treatment and assistance living in the community. There is a link below to the article reported in the news today. http://www.nytimes.com/2009/09/09/nyregion/09mental.html?_r=1&th&emc=th

The reason I am unsure, is that I think this is one small example of the problems created for those with severe and disabling mental health conditions with deinstitutionalization. It will be interesting to see what the next steps are resulting from this ruling. My hope would be that individuals will get care more tailored to their needs.

Another concern is that there are many individuals in far worse condition who are not even in a housing program and receiving services. So on the priority list, I think I would focus on those who are homeless or end up incarcerated because they have a mental health problem. Hopefully this ruling will not result in addition to the ranks of the homeless or incarcerated.

We have a big problem in this country with redefining mental health treatment systems of care. There are problems everywhere with this. The adult homes in NYC are just one example of how a ‘good thing’ (deinstitutionalization and even community based adult homes) can go bad…

Will new pathways and classifications be developed to understand mental health problems?

Genes and Disease… Will genetic links help us discover new ways to understand people with mental health problems? Will these genetic links help in the discovery of new treatments?

Here is a link to an interesting ‘genes & disease’ map to consider…
http://www.nytimes.com/interactive/2008/05/05/science/20080506_DISEASE.html?ref=health#
I can find Schizophrenia and SAD, but I can’t seem to find Bipolar disorder or depression here… can anyone locate it? (psychiatric dx are in green)
Here is the associated article to figure out what the map means. http://www.nytimes.com/2008/05/06/health/research/06dise.html?pagewanted=1

It is interesting to think about the possibilities that arise from studies of these shared links. As the article suggests, there may be drugs used in one disorder that could lead to new discoveries of treatments for genetically linked disorders. This is indeed exciting to consider, particularly in mental health. However the potential for discovery also relates to the mechanisms of action of the drug within the pathway of causality to a particular disorder. So it does depend greatly on how that genetic link cascades out into the actual physiologic abnormality.

There is some discussion of classification of disease in psychiatry in the article as well. One view is that Schizophrenia and Bipolar share some common genetic links. Given this, Dr. Berrettini from Penn suggests we have not correctly categorized disorders. The other view is that even with shared genes the two diseases are distinct. We have all had the experience (or for our newest students will have the experience) of considering whether an individual’s problem is actually schizophrenia or bipolar, and of course there is schizoaffective to consider too.

It is interesting to consider whether the groupings and categorizations we use in psych mental health are helpful (and in what way?).

It is also interesting to brainstorm and open our views to other possibilities of how we might understand and categorize the difficulties of the people we work with and try to help.

What are your thoughts on these categories?

What are your thoughts on the usefulness of considering the genetic links between disorders?

Homicide Committed by a Physician: Benefits of Boundaries in Professional Relationships

As I read the details of Michael Jackson’s death and relationship with his personal physician, I am surprised at how wrong this situation went ( Moore, S. (August 28, 2009). Jackson's death ruled a homicide. New York Times. see below). Then again, I am not that surprised. I think there is good reason that practitioners do not live with and become a part of the family of their patients. It is similar to why a practitioner cannot appropriately care for a family member. I admit I do smile to imagine what that lifestyle might be like, to live in the midst of such fame and fortune. It is incredibly appealing. It is easy to see why his physician chose to put himself in that situation.

Better however is the typical situation, where the structure of one’s practice aids the provider in maintaining some objectivity in judgment related to working with individuals with complex and difficult to treat problems. Better with a drug seeking patient, to only have to respond during the professional appointment time to the request for drugs vs. a 24/7 requirement to interact with your patient. Better with a drug seeking patient to have colleagues to discuss the case with when you are managing the complex problems arising in treatment.

How poorly managed Michael Jackson’s problems were. It seems fame and fortune do buy one the ability to deny problems and to purchase the kind of care one wants despite whether that care provides any real benefit. Yes, I am referring to his medication management and the multiple surgeries to change his looks, and I imagine fix the problems perhaps from the last surgery. Amazing that things could go so wrong.

Jackson received ativan (lorazepam), valium (diazepam) and versed (midazolam) within six hours of his death, along with the propofol which of course then rendered him unconscious as would be expected with an anesthetic, and the combination packing a strong wallop of respiratory depression from the combined effects of all of the drugs (with half life ranging from 1 to 4 hours for versed to 14 to 70 hours for valium). Of course we have no knowledge of the timing and doses involved, and I can only imagine the tolerance that was present.

We are taught some basic principles in developing a professional relationship with a patient. We maintain a particular role in that relationship. A role that would be difficult to maintain in a 24/7 relationship. Particularly if the patient is drug dependent and in denial about that. Imagine being begged to provide drugs to aid in sleep. I imagine the import of having his own live-in personal physician was to help Jackson be able to perform in this upcoming tour. So here is a practitioner faced with that very agreement: you pay me tons of money to live with you and be your personal physician, and I will treat your needs so that you can continue your career. That is a tremendous burden for an individual provider to take on. Particularly alone… In the middle of the night… and into the day… with a patient begging for drugs.

The boundaries we are taught in maintaining a professional relationship are helpful. Particularly in complex situations… With difficult patients... With patients we care about, and maybe have difficulty maintaining objectivity... With patients who are lavish in their spending for your services and for your presence. It seems the sweet deal Dr. Murray had with Jackson was not so sweet after all. There is good reason to rely upon the professional roles, structures and boundaries that protect not only us, but even more important our patients.

Moore, S. (August 28, 2009). Jackson's death ruled a homicide. New York Times. link: http://www.nytimes.com/2009/08/29/us/29jackson.html?scp=17&sq=michael%20jackson&st=cse

A New Site for Mental Notes...

I have decided to take my blog, Mental Notes (see link below), to a more public space. Unfortunately my title, "Mental Notes" was already taken here, so for now, this blog will be called Mental Notes by Joanne. The genesis of the blog, was to continue discussion with my clinical seminar students as ideas arose during the week.( to view my blog, visit http://blogs.yale.edu/roller/page/mentalnotes)

I haven't posted much lately, but now that I am nearly wrapped up with my busy spring semester, I will be devoting some time to blogging!