Dr. Henry Paul, MD

Psychiatrist, Author and Educator

INSURANCE COMPANIES AND THE MENTALLY ILL – A RESPONSE TO JUDGE ROBERT K. KILLIAN OP-ED LAST WEEK

June 30th, 2014

I would like to respond to the OP-ED in last week’s Hartford Courant by Robert K. Killian Jr., Hartford’s probate judge.  In “The Half-Truth about the Dangerously Mentally Ill” Judge Killian brings up many interesting and thorny issues regarding mental illness, danger, freedom, and public protection, but there is another issue that runs tangential to these. It is the fact that in our mental health system the insurance companies have made it nearly impossible to help people in hospitals at all. The days allowed in the hospital have been so seriously limited that patients are usually discharged before receiving any sensible treatment. Not only are they discharged before medication has even had a chance to work, but time is so limited that the staff has almost no time to assess the patient’s overall psychosocial circumstances and, of course, cannot come up with a logical plan for the patient after these micro-stays. Thus, the revolving door for so many patients eventually leads to demoralization and deterioration amongst the chronically mentally ill which, in turn, often results in early death, violent behavior due to chronic instability, other crimes, incarceration and even suicide. These insurance limitations are not isolated to big private insurance conglomerates, but to public insurance, as well.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

MEDIA HYPE ABOUT ANTIDEPRESSANTS MAY HAVE INCREASED SUICIDE ATTEMPTS IN TEENS

June 26th, 2014

Government warnings that antidepressants may be risky for adolescents, and the ensuing media coverage, appear to have caused an increase in suicide attempts among young people, researchers reported Wednesday. Warnings Against Antidepressants for Teens May Have Backfired, NPR Morning Edition, June 14, 2014. (Listen here).

I have been saying for a long time that too much media hype has surrounded the FDA warnings regarding the suicide risk of antidepressants for young people. The recommendations were exaggerated and magnified to the point that parents were afraid to treat their children. The reality is this, the drugs do help.

What the FDA was recommending at the time were that medical professionals, parents and school staff watch for signs that might be worrisome. All the time, the FDA has said increased suicidal ideas are a rare side effect. So how did this warning from the FDA get so out of control? I think that fear is what drove much of it.

“This was a huge worldwide event in terms of the mass media,” said Stephen Soumerai of the Harvard Medical School, a co-author of the study, which was published in the journal BMJ, on NPR Morning Edition this week. “Many of the media reports emphasized an exaggeration of the warnings.”

Having treated children and teens for more than 30 years, I know how difficult it is for parents to process their child’s disorder or illness, and, often, it is even more difficult to make treatment decisions that that they think could endanger their child further. Even with a doctor’s reassurance this is a trying time for parents, but it should not be scary.

Look, the FDA warnings were well intended, but what happened is that the media hype made some doctors and more parents reluctant to medicate leading to a drop in antidepressant prescriptions. According to the study, antidepressant use nationally fell 31 percent among adolescents and 24 percent among young adults, the researchers reported. Suicide attempts increased by almost 22 percent among adolescents and 33 percent among young adults, they said.

The bottom line is that the drugs do help. This leaves parents and doctors having to weigh the positive effects of the drugs against, what are in many cases, the rare side effects. Interestingly there are two new developments. I have heard that there has been consideration of removing the suicide warnings, and also, most recently, there was a report that it was only high dosing in young people that was associated with increased suicidal phenomena.  So, in summary we got a report that antidepressants can lead to suicidal thinking in young people, and, as a result, many prescribing doctors stopped prescribing them to depressed young people whose untreated depression itself could lead to suicide. For some reason, as yet unproven, the depression rate and suicide rate went up chronologically coincident with these developments. And now, at a time when there has been consideration of taking off the warning, a new study implies there might be a danger, but only when too high a dose is given at the initiation of treatment.

So what now? I prescribe these medications as needed. As usual, I routinely do follow ups on a frequent basis to check for all aspects of the response, including a detailed suicide assessment. I have yet to see any signs of increased suicidal fantasies that I can attribute to these drugs. I suggest that all parents develop a constructive relationship with the prescribing psychiatrist and not rely solely on social media or other sources of information.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

SO HOW DO OUR KIDS END UP IN GANGS?

June 21st, 2014

They poison our streets with drugs, violence, and all manner of crime.

“Some 33,000 violent street gangs, motorcycle gangs, and prison gangs with about 1.4 million members are criminally active in the U.S. today. Many are sophisticated and well organized; all use violence to control neighborhoods and boost their illegal money-making activities, which include robbery, drug and gun trafficking, fraud, extortion, and prostitution rings. According to the 2011 National Gang Threat Assessment report, gangs are responsible for an average of 48 percent of violent crime in most jurisdictions, and up to 90 percent in others. We’re redoubling our efforts to disrupt and dismantle gangs through intelligence-driven investigations and new initiatives and partnerships.” FBI.gov

The craving to find some sort of group identity is usually strong in adolescence, and it is normal for girls and boys to want to be part of a group to achieve some degree of identification with their peers. Many teens find nurturing group acceptance in sports teams, rock bands, or any other number of special-interest organizations that offers the opportunity to bond with like-minded teens. What is scary is when the tendency to bond “tribally” in adolescence is with a gang. While gangs offer their members a powerful sense of belonging, they also almost always lead to disaster for virtually every member.

2403390_sThe reality is that gang members almost always are into drugs, have committed violent acts, crimes and felonies – and yes, sadly this includes murdering or being murdered themselves. Gangs also present a danger to a member’s family and friends.

It is interesting, as we see this week, so many children are fleeing to the United States over the Mexican border. It is widely suspected that these children are coming from Guatemala, Honduras and El Salvador – countries battered by gang violence. Gangs are a worldwide problem that’s growing.

So what can we do to keep our children safe? Here are some things to do:

  • A teenager can refuse to join a gang: talk with your teen about resisting any intimidation tactics he may be experiencing from other gang members.
  • Encourage your teen to go to the police, parents, teachers, and other authority figures for help. Gang activity can and should be reported.
  • Getting involved in other activities – both group (sports and other special interest) and solo (hobbies, playing an instrument, and so on) options abound – can give your teen a healthy sense of purpose and belonging.
  • Increase parenting skills by attending parent-education groups – and especially any that address the dangers of gangs, so that you’ll know what to watch for in your teenager.
  • Set a good example: show, in your own life and dealings with other people, that there are healthy and satisfying modes of interaction your teen can pursue. This is the most powerful help you can give.
  • Know what your teen is doing and where he is, and make sure he is involved in supervised activities.
  • Praise your teen. Do what you can to bolster his self-esteem, the lack of which is a frequent motive for joining gangs and committing other antisocial acts.
  • Be very clear about your disapproval of gang activities.
  • As in virtually every other dilemma or potential problem your teen faces, family communication is essential. When you’re able to talk and listen to you teen on a regular basis, the odds go down that your teen will turn to a “new” family for guidance, identity, a sense of belonging, or other support.

And remember, girls will join gangs too! Gangs are not also just in the inner-cities any more. They are all across America – in our suburbs and rural communities, too. If you suspect your child is in a gang you should seek help. Speak to school personnel, local police, mental health community agencies, your clergy, but most of all to your teenager.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

A BULLYING VICTIM FIGHTS BACK AND THE RESULT IS DEADLY THIS WEEK IN NYC

June 21st, 2014

“In the weeks leading up to the violent encounter, there were signs that the dispute between the boys went beyond typical bullying.” The New York Times, June 18, 2014 Signs of Trouble Preceded Fatal Stabbing at Bronx School

Nearly all of the studies done on the effects of bullying focus on the harmful effects it has on victims, and on the prevention of the bullying in the first place. But in New York City this week we have an incident involving the killing of a bully by a victim. News reports describe intense bullying of the killer. Supposedly the bully ran in a pack who increasingly sought to scare, intimidate and hurt the killer and his family. So now we see a new side – vengeance!

It is not surprising that such an incident occurred. After all, being bullied usually leads to a state of impotent rage with the impotence leading the way to depression, demoralization and even self-destruction. But the rage exists and, in some, this will surface and sometimes it will be acted on, as it was here. I expect that the headlines and efforts will turn towards helping victims not turn to such measures. And, of course there is the fear that the supporters of such revenge tactics might take this up as a good thing, and we might see a return to some vigilante-like activities as we have before.

Our goal must be to keep our focus on prevention in the first place. The complex phenomenon of bullying must remain our focus with particular emphasis placed on organizing and improving anti-bullying messages and programs in schools and communities. Only in that way will the tragic lives of bullies and their victims ever get under control.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

A SURGE IN BIRTHS OF DRUG-DEPENDENT BABIES

June 19th, 2014

“No one who hears it ever forgets the sound.

When newborn babies begin to withdraw from powerful drugs, they shriek at a high, telltale pitch. Cut off from the substances they ingested through their mothers, they convulse, projectile vomit or writhe from skin-scorching diarrhea.

Their tiny bodies shudder violently. They cannot be consoled.”  

Quote from USA TODAY, June 2015, “Drug dependent babies challenge doctors, politicians”    Shelley DuBois and Tony Gonzalez, The Tennessean

The state of Tennessee has been monitoring a growing epidemic since the beginning of 2013 – a surge in births of drug-dependent babies. The state is dealing with a pain medication epidemic that is claiming the tiniest victims – newborn babies! Last year, 921 babies were born addicted in the state and now, Tennessee is fighting back by cracking down on what is known as “doctor shopping” — a trend that is all about finding a doctor that will prescribe pain medications. For an addict this means they can get multiple prescriptions to fuel their habit.

With Tennessee’s 2012 Prescription Safety Act things have changed for the better. The new database system flags people who try to get drugs from four or more sources. This amped up state prescription database requires doctors and pharmacists to use it when doling out pain meds. What a great idea! Why didn’t we think of this sooner?

As we have seen over-and-over for the past six months abuse of, and addiction to, Opioids (prescription painkillers) has skyrocketed leading to a heroin epidemic, and now, an epidemic of drug-dependent babies. Babies born addicted have to go through an excruciating drug withdrawal, known as neonatal abstinence syndrome (NAS). These babies can have seizures, brain damage and in later years school difficulties and behavior problems.

The complicated issue here is that the mothers are victims, too. Many are prescribed these addictive medications by a doctor to treat their pain. These women not only become addicted to the pain medications, but they also become pregnant. Once pregnant they become fearful of discussing their addiction with their doctor, family or friends. What needs to be understood is that there are two victims who need treatment – mother and child. This is a very heart-wrenching time for both and so compassion and understanding are necessary. Also, necessary are laws that make women feel safe so they can seek help for their addiction, and not fear losing their babies.

If you suspect that a friend or loved one is addicted to pain medications and pregnant you should talk about it with them, suggest they speak with their doctor, not be judgmental and help them to find the correct treatment.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

GOVERNOR CUOMO RECOGNIZES THE HEROIN EPIDEMIC AND IS DOING SOMETHING ABOUT IT

June 16th, 2014

“I’ll be the first to say to you: New York State has a problem with heroin addiction, and it is a growing problem,” Mr. Cuomo said on Wednesday in a speech announcing the move, his first major address on heroin. “In the ’70s we had a heroin epidemic. This is worse than what we went through before.” The New York Times

17463078_sI was glad to see New York Governor Andrew Cuomo address the heroin problem in the State. As I have been talking about in my blog, this is much more than an epidemic — It is a crisis! And, not just in New York State, but across the country. It is the result of many things, but much of the increase in heroin use among suburban teens and a growing number of adults coincides with a sharp rise in the use of prescription painkiller pills, which are quite similar to heroin.

According to the NY Times article, “the announcement comes as the resurgent abuse of heroin has been discussed intensively in Albany. For weeks, lawmakers have been meeting treatment providers, insurance companies and families who have lost relatives to overdoses to discuss heroin addiction and the opioid pill abuse that serves as a frequent gateway to heroin.”

Back in my April blog, I addressed the news stories that were coming out about young adults and teens struggling with heroin addiction, and the shock and awe that families felt when they suddenly realized that they had a loved one who was using. At that time, Vermont, Governor Peter Shumlin devoted his entire State of the State message to the heroin addiction. So I can say that I have seen this coming — the drugs are no longer just in the cities, but they are now in our suburbs, rural communities and high schools across the country. That is scary!

I am glad to see that the Governor’s legislation involves new officers being added to drug units around the state. It is a good start. I believe that Governor Cuomo’s efforts are a good start and can make a difference, but we ALL have to be vigilant, too. We must work together! The most important thing is for everyone, particularly parents and the healthcare community, to understand and recognize the symptoms of addiction, and to seek help if you suspect there is a problem. Here are some things that you need to know about heroin addiction:

  • Know the symptoms. These can include a change in personality, lying, stealing of money or medication, sudden drop in grades, depression, pinpoint pupils and signs of intoxication.
  • The first thing is to seek professional help. Treatment for heroin addiction, in addition to detoxification, sometimes includes the use of methadone, which is not intoxicating or sedating, but suppresses narcotic withdrawal. Methadone also relieves the craving for heroin. LAAM is a synthetic opiate that is used to treat heroin addiction.
  • Detoxification is necessary for most addicts. This is usually done in a residential center but sometimes in an out-patient facility.
  • Behavioral therapy is often effective, involving contingency-management therapy and cognitive-behavioral therapy. As with other drugs, 12-step programs can help reinforce the decision to stop using heroin once the addict has navigated the difficult straits of withdrawal.
  • Psychotherapy along with certain psychiatric drugs is also common and useful to control urges and yearnings, as well as to help with the many common underlying psychiatric disorders of addicts, especially mood disorders.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

HAVE THE LIMITS FINALLY BEEN PUSHED WITH “SLENDER MAN”?

June 6th, 2014

Teenagers today are faced with a far wider range of media influences, subcultures, and social choices than ever before. That is why the news that two 12-year old teenage girls lured another 12-year old girl into a game of hide-n-seek that almost turned deadly is so shocking. Just the bizarre nature of the attack has stunned parents and families across the country. And who is this Internet meme “Slender Man” anyway?

As a child psychiatrist, who has treated children, teens and young adults for more than 30 years, this is truly an unsettling story. Slender Man is featured on the Creepypasta Wiki website. A website that compiles tales of fictional horror, where much of the fascination with Slender Man is rooted in the overall mystery of him and his purpose – that remains unknown. He is known to kidnap children, and they are never found.

Apparently, according to a news report by NBC affiliate WGBA in Green Bay, WI., one of the attackers told law enforcement that they wanted to” become “proxies” of the faceless character, and would have to prove their dedication with killing. They planned to take their victim’s body to a part of Nicolet National Forest in Wisconsin’s north woods, where Slender Man supposedly lives.”

So what happened here? How could two young girls do something like this? Unlike the “good ole days” when news was disseminated by media outlets today it pours out on hundreds of channels and countless websites. Children are thus exposed to an enormous amount of gore, disaster, and sexually charged and other possibly trauma-inducing topics and themes. Music videos (not to mention the lyrics) depict graphic sex and violence as if it were completely normal and desirable, and many radio shows and Internet websites seem obsessed with different forms of violence and cult followings. For many adults, we turn this stuff off, but for children and young adults they aren’t always so quick to do so. This has a confusing and deeply disturbing impact on youngsters.

For many years, there has been debate over the effect of media on childhood development. The tide has been changing to considering that exposure to media violence is a negative phenomenon. Of course, there would only be a very small minority of children who would ingest such material and act it out as these girls have, but never the less we have to know what our kids are exposed to. It seems like these girls were overly vulnerable to the effects of what they saw and their immaturity might have been a factor. But also in general there are types of developmentally fragile young people who should be sheltered from such material. The degree of being able to separate fantasy from reality varies from one child to another. As young people get older, we expect that the degree of impressibility decreases, but not for all children. So we must know our children and know what they watch and listen to and not be shy about limiting exposure.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

PARENTS NEED TO KNOW!

June 6th, 2014

Between “Slender Man” and shootings, yes another one today on a campus in Seattle, the news this week has made a lot of parents wonder about what their children, teens and young adults are watching, listening to, and engaging in online. It is important to understand what is influencing your child. Here are some things you need to do:

  • Parents should find out what media engage their teenagers. This mean knowing how often your teenager watches television, listens to radio, and surfs the Internet, as well as knowing what music and music videos he/she listens to and watches. This task of educating yourself about your teen’s media exposure is extremely important. It may involve watching television shows you know your teen habitually watches (with or without your teen); and listening to music, radio shows, and so on that that personally you may not find palatable but your teen does. You can’t understand the impact of media if you don’t know what in it attracts and absorbs your teen.
  • Set rules in your home about the media. Reasonable limits should be set and adhered to.
  • Encourage your teen to get involved in athletics, the arts, or other activities. Teenagers should not be allowed to become passive recipients of an overload of media.
  • Talk with your teen about what he/she is watching and listening to. Try to get a sense of why it absorbs him/her. This is especially important in the areas of sex and violence. Let your teen know that these are important issues and that they shouldn’t be dealt with superficially.
  • Parents should find out what is constructive in media and encourage teens to take part in it. There are many programs, talk shows, and even musical experiences that can be quite thrilling, uplifting, fun, and educational. Much worthwhile culture can be gleaned and enjoyed through the media.
  • Stay around your teen when he/she watches TV or videos or surfs the Internet. The simple presence of a parent is often enough to remind the teen of limits you have agreed to about what and how much media to consume.
  • Help the school system your teenager attends develop educational programs about exposure to media.
  • Become as familiar as possible with cultural and sub-cultural trends to which the media exposes your teen. This is not meant to imply that you should pretend to be as “cool” as your teen, but simply be knowledgeable about what’s going on. Again, you can’t help your teen deal with media influence if you don’t know what the influence is.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

PREDICTING THE NEXT SHOOTER

June 4th, 2014

The debate about gun control will undoubtedly be fueled by this latest shooting in California. But the dialogue that needs to happen is about recognizing the problem. The question we need to ask is “What do you do when you think someone is dangerous to others?”

For the parents of Elliott Rodger, and a psychiatrist who treated Denver shooter James Holmes, they did recognize something was wrong. In the case of Rodgers the parents tried to contact law enforcement, who, when they checked on Rodger, found him to be okay. The parents knew that not to be the case, so now we have to ask “What more could they have been done?”

The simple fact is that all of us have blind spots because some truths are too much to bear. This is especially true when we feel that a person is getting out of control. Rage, anger, violence and abuse are very frightening things to experience for all of us, and, as a result, we shy away from confrontation. We get scared and hope it passes. We try to rationalize away irrational rage. When we are frightened our judgment gets clouded and decisions we make are often made to allay our own discomfort.

Reporting about a family member or friend also brings all sorts of anxiety. First, we might fear becoming a target of the destructive rage if we confront the person or suggest intervention. Second, we don’t want to make the whole thing worse. We might picture a physical altercation where we become the victim. Thus, the whole subject evokes a good deal of anxiety.

As a psychiatrist, I have even seen this anxiety in professionals who work in the field, too. Unconsciously, professionals can also become scared dealing with a patient who talks about mass shootings and murder. In these cases, the therapist might unconsciously change the subject to suicide rather than talking about killing others. In these instances, because of the anxiety created around the discussion the therapist may give shallow advice such as suggesting increased exercise to calm someone down. Sadly, I have even seen angry patients dismissed from care because of therapist anxiety. The dismissal is usually rationalized in some way. At the very least, I have seen people with overt red flags who are not probed enough or who are sent on their way because the professional is reluctant to become more deeply involved in discussing the details of their fantasies for fear of going to an uncomfortable place. This is why continued clinical practice and training and peer support remain such necessary tools. There are also professional violence screening tools which help in the consultation room.

Professionals and lay people alike should always ask for help when confronted with such anxiety-inducing situations. We are all human and prone to anxiety. There is no shame in being anxious. Reaching out can sometimes save a life. We will never be able to predict and prevent all violence, but there is a room for improvement.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.