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?