Monday, November 10, 2014

Native Americans and Suicide

By Arshya Vahabzadeh, MD & Brad Zehring, DO

Mental illness does not discriminate - it affects every age, sex, religion, and ethnic group.

The Indian Health Service conducted a study in 2008 that noted that the rate of suicide for American Indians and Alaska Natives is higher than any ethnic group within the United States. The study reported that suicide in these populations is up to 70% higher, especially in ages 10 to 24. Sadly, this statistic is not decreasing. Mental health professionals and society need to recognize the etiology of the despair that leads to suicide so that treatment and appropriate allocation of resources can be made.

The statistics are alarming, but possibly more alarming is the silence around this tragedy. Since suicide is taboo on most reservations - there are reports that a death by suicide often is not reported or legal authorities classify it as an accident. Due to the silence and misrepresentation, the numbers could be even greater.

It is important to break the silence on the troubling trends within Native American reservations. Native Americans must be willing to discuss their stressors and be open to getting education necessary to cope, deal, and treat their stressors. Mental Health professionals must be willing to understand their culture and adapt. Alex Crosby, MD, MPH, medical epidemiologist of the CDC has been recorded as saying that Native American suicide is so prevalent that it has become acceptable practice when tensions build up. Suicide should never be an acceptable option.

Reasons for troubling trends among Native Americans
There are a lot of thoughts on why mental illness and suicide have increased in the Native American population. There has been a lot of discussion of generational trauma due to the disempowerment and oppression of Native Americans and Alaska Natives. It has been discussed that this has caused adverse childhood experiences that lead to high rates of depression and other mental illness that are precursors to suicide.

While disempowerment and oppression could very well be contributing factors - poverty seems to be a growing problem on reservations. Poverty tends to put stress on educational standards decreasing the educational opportunities for those on the reservation – leading to a viscous cycle. There are few jobs on the reservation causing adolescents and young adults to leave their families and move to where there are jobs. However, parents age and get ill causing tension between the traditional Native American family structures where youth takes care of the elderly and providing for the immediate family.

In addition to poverty, substance abuse is a big problem on the reservation. Substance abuse can affect mood, often negatively, which increases the tension and is a risk factor for suicide. Domestic violence and sexual assault are also known problems on the reservation. These stressors have led to unstable environments for children growing up. Add untreated mental illness to the mix and it is easy to see how hopelessness and despair thrive often leading to the belief that suicide is the only way out.

The Way Forward
Recently, the American Foundation for Suicide Prevention joined a Native American Mental Health panel sponsored by Congressional Native American Caucus and Center for Native American Youth. The panel focused on ways of improving mental health resources and suicide prevention. The IHS and the Substance Abuse and Mental Health Services Administration (SAMHSA) collaborated on targeted suicide prevention programs. The IHS established the Suicide Prevention Initiative and SAMHSA provided funding to the IHS to address youth suicide and provide suicide prevention for high-risk populations.

As we move forward as Mental Health professionals, it will be important to continue to collaborate with the Native American population, especially with Mental Health professionals with experience with the population and their culture. Understanding their culture and etiology of stressors will go a long way in providing the appropriate resources and treatment.
Resources for Help
In the US:
·         Suicide help
·         1-800-273-TALK

Outside the US:
·         International Association of Suicide Prevention (IASP)

Monday, October 20, 2014

15 Tips for Talking to Kids about Ebola

By David Fassler, M.D.
Child and adolescent psychiatrist 
Parents and teachers may find themselves faced with the challenge of discussing the evolving Ebola epidemic with children. Although these may be difficult conversations, they are also important. There are no “right” or “wrong” ways to talk with kids about Ebola, but here are some suggestions if you need help. 
1. Provide an open and supportive environment where children know they can ask questions. At the same time, it’s best not to force children to talk about Ebola unless and until they’re ready.
2. Answer questions honestly. Kids will usually know, or eventually find out, if you’re “making things up." It may affect their trust in you or your reassurances in the future.
3. Use words and ideas children can understand. Gear your explanations to the child’s age, language, and developmental level.
4. Help kids find accurate and up to date information. Print out Fact Sheets from the CDC, CNN, WHO and
5. Be ready to repeat information and explanations several times. Some information may be hard to accept or understand. Asking the same question over and over may also be a way for a child to ask for reassurance.
6. Acknowledge and validate the child’s thoughts, feelings, and reactions. Let them know that you think their questions and concerns are important and appropriate.
7. Remember that kids often personalize situations. For example, they may worry about their own safety and the safety of family members. They may also worry about friends or relatives who travel or live far away.
8. Be comforting, but don’t make unrealistic promises. It’s fine to let children know that they are safe in their home or at school. But you can’t promise that there will be no cases of Ebola in your state or community.
9. Let kids know that there are lots of people helping the families affected by Ebola. This time is a good opportunity to show children that when something scary or bad happens, there are people to help.
10. Children learn from watching their parents and teachers. They will be very interested in how you react to news about Ebola. They also learn from listening to your conversations with other adults.
11. Don’t let kids watch too much television with frightening images. The repetition of such scenes can be disturbing and confusing.
12. Children who have experienced serious illness, loss, or other traumatic events in the past are particularly vulnerable to graphic news reports or images of death. These children may need extra support and attention.
13. Watch for physical symptoms including headaches and stomachaches. Often times, kids express anxiety through physical aches and pains. An increase in such symptoms without apparent medical cause may be a sign that a child is feeling anxious or overwhelmed.
14. Children who are consumed with questions or worry about Ebola should be evaluated by a trained and qualified mental health professional. Other signs that a child may need additional care include: ongoing sleep problems, frequent fears about illness or death, or reluctance to leave parents or go to school. If such behaviors continue, ask your child’s pediatrician, family physician, or school counselor to help you contact a mental health professional. 
15. Although parents and teachers may follow the news and the daily updates with interest and attention, most kids just want to be kids. They may not want to think about what’s happening across the country or elsewhere in the world. They’d rather play ball, climb trees, or ride bikes.
Public health emergencies are not easy for anyone to comprehend or accept. Understandably, many young children feel frightened and confused.  As parents, teachers, and caring adults, we can best help by listening and responding honestly and comfortingly. Fortunately, most children, even those who have experienced loss or illness, are quite resilient.  However, by creating an open environment where they feel free to ask questions, we can help them cope with stressful events and experiences.

David Fassler, M.D., is a child and adolescent psychiatrist practicing in Burlington, Vermont. He is also a Clinical Professor of Psychiatry at the University of Vermont.

Tuesday, October 7, 2014

Adult Bullying in the Workplace

By Brad Zehring, DO
I would rather be a little nobody, then to be an evil somebody - Abraham Lincoln

Typically, when bullying is talked about it is in the context of children or adolescents during some level of schooling. Rarely do we think about bullying as an adult issue. However, much more attention has been focused on adult bullying – more specifically, adult bullying in the workplace.

According to various sources, citing research and survey’s, it has been reported that as many as 1 in 4 adults will face some form of bullying in their career.  It is important to point out the differences between constructive criticism, workplace conflict, and bullying. Workplace bullying focuses on the person rather than the performance or task being completed by the person. In addition, the person being targeted feels powerless to stop it. Making the situation worse, is when the adult being bullied goes to management to report the offense and the abuse is minimized or discounted altogether. Complicating the issue further is the difficulty verbalizing what is taking place or being unaware that what is occurring is bullying, leading to worsening suffering.

What are some forms of workplace bullying?
As discussed earlier, workplace bullying can be described as an extreme pattern where the person is isolated apart from his/her performance or task. Some examples of workplace bullying are: being left-out of work-related social events, coworkers refusing to help when asked, coworkers leaving the room when you enter or routinely arriving to meetings late that when you call them, being yelled at, put down, or disciplined in front of your coworkers. These are some of the ways that workplace bullying presents, but it is not an exhaustive list.

How workplace bullying is harmful
For individuals who are being bullied in the workplace, their desire to go into work day after day is diminished and their satisfaction in their performance and with their employer decreases.  Many reports discuss the loss of productivity when job satisfaction decreases. Beyond the psychological stress (depression, anxiety, PTSD, etc) – which should not be minimized, stress from bullying can lead to physical illness such as stroke, heart attacks, chronic fatigue or dissatisfaction in an person’s personal life – including leading to suicide. There are many reports documenting poor job satisfaction negatively affecting all areas on one’s life. Feeling accomplished and satisfied in a career can lead to a happier personal life and vice versa.

How to prevent or deal with workplace bullying
While recognizing or speaking up about workplace bullying can be a difficult task - it is important not to be silent about bullying experiences, whether personal attacks or witnessed attacks on colleagues, or isolate from those that may be able to help. Currently, states are working on anti-bullying bills to encourage healthy workplace environments, but fostering a workplace for your coworkers that doesn’t tolerate bullying is key. Many organizations provide or contract with mental health professionals willing to discuss, advise, and help an individual navigate the process. It is important to document your concerns and be specific and concise with the message you are trying to convey if you feel you are being bullied. Despite how difficult it may be, it is important to approach the bully or go to your supervisor with a calm demeanor and discuss your concerns rationally. Lastly, it is important to have an open mind about the situation. Sometimes it may be that the “bully” does not realize how his/her actions have affected you. Approaching them, or the situation, calmly will provide an environment for understanding and increase the probability for change.

Friday, August 22, 2014

Williams’ death reminds us that a patient’s relief might be a warning sign

By H. Steven Moffic, MD

One of my favorite movie moments is when Robin Williams signs on as an edgy D.J. by exclaiming "Good Morning, Vietnam" from the 1987 movie of the same name. Sometimes, I played the audio over and over, as if it could promise a good day. As he did so often, he found a way to not only lighten the sadness, but to do it in such a way that might be constructively critical.
Surely, the real life mornings were not often happy ones, as so many of our troops died or ended up with post-traumatic stress disorder (PTSD) from that war. It is a lesson we are still learning, so that movie and his role is worth seeing again soon.

Now, after his reported suicide, that good morning seems more like a final good night.
Although he is probably best known for his manic comedy, he also played many serious roles. Most ironically now, he won an academy award in 1997 for playing an empathic therapist in the film “Good Will Hunting.”
Indeed, beloved entertainers like Robin Williams have a therapeutic role of sorts for society in the sense that they provide some relief—even if briefly—for the grief and stress of everyday life. For playing that societal role, such people become a repository for our hopes, dreams and demons. As we know for so many famous entertainers, it is not easy for them to have a successful private life—a private life that the public also tries to invade, as if they were related to us.

What we do know publicly is that Williams suffered from chronic depression and intermittent substance abuse. It is reported that he received treatment, including entering rehab just last month. Obviously, money to get the best treatment was not an issue, though how good the treatment was will remain unknown. We do know, however, that wealthy VIPs often receive treatment just as poor as low-income folks without resources. We also know that occasionally depression is a terminal illness, though that ending is not predictable.
Beyond the public information, and despite the understandable curiosity, this is not the time, nor should it ever be the time, to speculate about his diagnosis and reasons for committing suicide. In fact, the so-called "Goldwater Rule," called that for the inappropriate professional speculation about presidential candidate Barry Goldwater, ethically prohibits such speculations on the part of psychiatrists like myself.

Given this professional ethical principle, as well as the family's request for privacy, is there anything we can still learn from this apparent tragedy? The most intriguing detail that caught my attention was his last tweet and Instagram on July 31. Reportedly, he had wished his daughter a happy 25th birthday.

Why might this positive communication be of importance to us?
It reminded me of the only patient I ever had who committed suicide, long ago, when I was a resident in training. In the second session, the depression of this elderly man seemed to be less severe, but after that session he walked into Lake Michigan and drown. In the psychological autopsy, I never forgot the warning that when a depressed patient starts to seem better, they actually can be at higher risk for suicide.

Risky time
Why is that time of apparent improvement a risky time? The person can have more energy, then plan and complete a suicide. They may also feel relief at their decision, causing others to paradoxically feel relief. That is one of the reasons why it is so common to hear of the genuine surprise that the suicide occurred, as the person seemed to be happier.

What this means, not only for professionals, but for the public, is not to take at face value if a depressed person seems better. Be sure there is a sound explanation for the apparent improvement. 
Our only consolation must be that entertainers like Robin Williams keep on living in the form of their life’s work, like the movie “Good Morning, Vietnam,” that is so ubiquitously available nowadays. Even so, it would not be surprising if at the times we laugh once again at Robin William's humor, that the laughter will also be accompanied by some tears of grief.

H. Steven Moffic, MD, is a Life Fellow of the APA. Currently, he blogs regularly for Psychiatric Times, Behavioral Healthcare, and The Hastings Center's Over 65.

This blog was originally published in Behavioral Healthcare.

Tuesday, August 19, 2014

Spreading Hope!

By Matt Goldenberg D.O.
“You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome.” 

I whole-heartedly agree with that statement. However, I cannot take credit for those words. Those are the words of Robin Williams, or more specifically, the words of his character in Patch Adams.

I want to discuss the disease called depression. I will start by first discussing the diagnosis and the signs and symptoms of depression. I will then follow up with my thoughts on the various treatment options for depression and the strategies I employ with my patients to improve their outcomes. None of my thoughts and suggestions should serve in place of a formal consultation with a mental healthcare provider. However, I hope shedding light on mental health diagnoses like depression will lift the veil and social stigma on these chronic diseases that impact so many people.

Psychiatry has come a long way in the last decade. This is a time of continued discovery and increasing public awareness. The leaders of our professional organization, the
American Psychiatric Association (APA), have suggested that we as mental health professionals are under a microscope. I agree that we are and I also strongly believe that we are up for the challenge. School shootings and celebrity suicides and overdoses have increasingly put a focus on mental health. Psychiatry has significantly improved the outcomes, treatment options and the prognosis of patients with mental illness. However, we still are unable to decrease the prevalence of the diseases we treat or prevent them. We know that the brain changes during an episode of depression and our treatments help it to return to normal (see the image below). Although we are getting closer, we still currently do not have widely accessible blood or imaging tests that can confirm our diagnosis or localize the area of disease.

I can say with certainty, however, we are able to accurately diagnose patients. We are able to identify medications, psychotherapies and other treatments that patients with a specific diagnosis or cluster of signs and symptoms often benefit from. There is strong evidence that our treatments decrease symptomatology and disability and improve quality of life, clinical outcomes and a patient’s prognosis.

Psychiatrists are trained to view the patient as a “whole person”. Psychiatry is a field of medicine whose assessment by definition includes all of the biological, psychological and social aspects of a patient’s life. We listen for the psychological and social factors that can contribute to disease. Oftentimes, the “whole story” can be more telling than only focusing on specific symptoms of a given disease. There is a saying, throughout all fields of medicine, that “most patients have not read the textbook.” In other words, patients usually do not present exactly as the textbook says they should. Stress and psychological factors can mimic chest pain, shortness of breath, gastrointestinal problems and a whole host of other diseases. If we do not step back and get the whole story, we can miss the root cause or the exacerbating factors of many manageable diseases which are of the mind.

Many of the diseases we treat, such as depression, are chronic illnesses which require lifelong treatment. Our treatments can improve a patient’s mental health and coping skills and decrease their symptomatology and substance use. We know through decades of research that these are modifiable risk factors for suicide. Therefore, Psychiatrists have the training and tools necessary to decrease a patient’s risk of attempting suicide. Our treatments have the potential to not only significantly improve the lives of our patients, but also the lives of their families and everyone who comes into contact with them. Anyone who tells you otherwise is misleading, misinformed or both.
I hope this information and the blogs to follow will give you hope. Mental illness can include symptoms which can be devastating and complications which can be life-threatening. However, it is important to state again, these are treatable diseases. If you or someone you know, would like to talk to someone, call your primary care doctor or your insurance company for a referral to a Psychiatrist. A true multi-disciplinary team also includes therapists, psychologists, nurses and social workers. You are never alone. You can call the national suicide helpline 24 hours a day, seven days a week (1-800-273-TALK (8255) or visit There are also local crisis lines likely available in your area and are an internet search away. If you are ever feeling unsafe, or fearing for the safety of a loved one, you can call 911 or go to the nearest emergency department.
It is time for everyone to understand that there is no shame in getting help for depression, much as there is no shame in getting help with diabetes or high cholesterol. Even if you have never suffered from depression, there is a lot you can learn.
Together we can raise awareness and spread truth and hope. I know that if we spread knowledge, and ignore the misinformation, we will overcome the complacency and ignorance that is so pervasive today. That is how we can best honor those we have lost. That is how we can best prevent the next death from mental illness and addiction.