Monday, March 30, 2009

Trying to do the Right Things

I remember my mother's psychiatrist, years ago, telling me that the doctors in his profession were leaving the field in droves. This article is one of the reasons why. Most doctors have a conscience and try to do the right thing with their patients, but either families or the laws get in the way of treatment that makes sense. I see that the problem still exists.

IMAGINE YOU live in a small town, and your son is found to have a brain tumor. Faced with such a devastating illness, you would not hesitate to find the means to get to a medical center, even if it were in a city more than an hour from your home. You probably would search for high-quality specialists to provide the best care possible.

But consider that your son has another serious illness affecting his brain, but one you cannot see on a scan. I am referring to serious mental illness. Rather than assuming that this child deserves to have access to the same specialized care, our culture has colluded in the belief that a primary care doctor will be an acceptable provider of care.

As a pediatrician I take care of many children diagnosed with attention deficit hyperactivity disorder. For this problem I consider myself well qualified to provide excellent care. But often, what starts out as a diagnosis of ADHD proves to be much more complex. One child (I have changed details and combined stories in order to protect the privacy of my patients) did well enough for several years, but began to display increasingly angry and aggressive behavior. I made multiple adjustments in her medications, all along expressing concern to her mother. There were many obstacles to getting an appointment with either a therapist or child psychiatrist, so I continued to treat her.

Then one day, she told me she was so angry that she feared she would hurt someone. I notified the local crisis team, making it clear that I knew this family very well, that I was worried about her, and that I wanted to be called after she had been seen. No one called. They simply referred her back to me to adjust the medication.

Now I was both worried and angry. I called the one local psychiatrist who accepts the family's insurance. He told me that until he could be sure that the patient's insurance would go through, "she's your responsibility." I explained to him (not in a nice voice) that I had reached the limits of my expertise, that this girl and I both needed his help. After more days of multiple calls, she had an appointment with both a therapist and a child psychiatrist.

Another patient who had a history of severe abuse as a young child followed a similar course. For several years he did OK on his ADHD medication. But he began to fail in school. He was extremely anxious. After a particularly explosive and frightening scene that included threats of self harm, I told his mother that I was referring him to a child psychiatrist.

After jumping through multiple hoops, I was able to find a psychiatrist who had room in his practice. Yet a month later, I got a message in my office requesting a refill of his medication. I called his mother to clarify my plan to transfer his care to a child psychiatrist. She was upset that the psychiatrist's office was an hour away and wanted to keep things the way they were. When I again explained that her son needed more help than I could offer, she yelled at me, "You're just leaving us out in the cold!"

So how have we gotten to this unfortunate situation where primary care doctors, who are clearly not qualified, are expected and encouraged to treat children with serious mental illness? I believe three main factors are at work. First, the pharmaceutical industry has been successful at promoting the idea that a pill will fix these often complex problems. Second, the insurance industry has made it very difficult for primary care doctors to refer patients for any mental health services. And third, there is a severe shortage of child psychiatrists.

Together these factors have converged to back us into a corner. If primary care doctors do not provide this care, the child will not get care, and we will be in effect abandoning our patients. This is an unacceptable situation. We must address this problem on all three fronts in order to ensure that these seriously troubled children have the same access to care as a child with a brain tumor.

Dr. Claudia Gold, a pediatrician, practices in Great Barrington.

Sunday, March 22, 2009

Another Area that need fixing

I have personally seen some questionable people in nursing homes who fit this description. This is another area that needs to be watched carefully.

AP IMPACT: Mentally ill a threat in nursing homes

CHICAGO (AP) — Ivory Jackson had Alzheimer's, but that wasn't what killed him. At 77, he was smashed in the face with a clock radio as he lay in his nursing home bed.

Jackson's roommate — a mentally ill man nearly 30 years younger — was arrested and charged with the killing. Police found him sitting next to the nurse's station, blood on his hands, clothes and shoes. Inside their room, the ceiling was spattered with blood.

"Why didn't they do what they needed to do to protect my dad?" wondered Jackson's stepson, Russell Smith.

Over the past several years, nursing homes have become dumping grounds for young and middle-age people with mental illness, according to Associated Press interviews and an analysis of data from all 50 states. And that has proved a prescription for violence, as Jackson's case and others across the country illustrate.

Younger, stronger residents with schizophrenia, depression or bipolar disorder are living beside frail senior citizens, and sometimes taking their rage out on them.

"Sadly, we're seeing the tragic results of the failure of federal and state governments to provide appropriate treatment and housing for those with mental illnesses and to provide a safe environment for the frail elderly," said Janet Wells, director of public policy for the National Citizens' Coalition for Nursing Home Reform.

Numbers obtained through the Freedom of Information Act and prepared exclusively for the AP by the Centers for Medicare and Medicaid Services show nearly 125,000 young and middle-aged adults with serious mental illness lived in U.S. nursing homes last year.

That was a 41 percent increase from 2002, when nursing homes housed nearly 89,000 mentally ill people ages 22 to 64. Most states saw increases, with Utah, Nevada, Missouri, Alabama and Texas showing the steepest climbs.

Younger mentally ill people now make up more than 9 percent of the nation's nearly 1.4 million nursing home residents, up from 6 percent in 2002.

Several forces are behind the trend, among them: the closing of state mental institutions and a shortage of hospital psychiatric beds. Also, nursing homes have beds to fill because today's elderly are healthier than the generation before them and are more independent and more likely to stay in their homes.

No government agency keeps count of killings or serious assaults committed by the mentally ill against the elderly in nursing homes. But a number of tragic cases have occurred:

_ In 2003, a 23-year-old woman in Connecticut was charged with starting a fire that killed 16 fellow patients at her Hartford nursing home. A court guardian said Leslie Andino suffered from multiple sclerosis, dementia and depression. She was found incompetent to stand trial and committed to a mental institution.

_ In 2006, 77-year-old Norbert Konwin died at a South Toledo, Ohio, nursing home 10 days after authorities said his 62-year-old roommate beat him with a bathroom towel bar. Sharon John Hawkins was found incompetent to stand trial.

_ In January, a 21-year-old man diagnosed with bipolar disorder with aggression was charged with raping a 69-year-old fellow patient at their nursing home in Elgin, near Chicago. A state review found that Christopher Shelton was admitted to the nursing home despite a history of violence and was left unsupervised even after he told staff he was sexually frustrated.

Jackson's roommate was 50 and had a history of aggression and "altered mental status," according to the state nursing home inspector's report. Solomon Owasanoye wandered the streets before he came to All Faith Pavilion, a Chicago nursing home, and he yelled, screamed and kicked doors after he got there.

On May 30, 2008, he allegedly picked up a clock radio, apparently while Jackson slept, and beat him into a coma. Exactly what set him off is unclear. Jackson died of his injuries less than a month later. Owasanoye pleaded not guilty to first-degree murder, and after a psychiatric review was ruled unfit to stand trial. He now lives in a state mental hospital.

All Faith Pavilion co-owner Brian Levinson said his staff is trained to deal with aggressive behavior, and he disputed state findings that Owasanoye had a history of aggression. The for-profit nursing home was fined $32,500 for failing to prevent the assault.

Under federal law, nursing homes are barred from admitting a mentally ill patient unless the state has determined that the person needs the high level of care a nursing home can provide. States are responsible for doing the screening. Also, federal law guarantees nursing home residents the right to be free from physical abuse.

Families have sued in hopes of forcing states to change their practices and pressuring nursing homes to prevent assaults. Advocates say many mentally ill people in nursing homes could live in apartments if they got help taking their medication and managing their lives.

The problem has its roots in the 1960s, when deplorable conditions, improved drug treatments and civil rights lawsuits led officials to close many state mental hospitals. As a result, some states have come to rely largely on nursing homes to care for mentally ill people of all ages.

Also, mixing the mentally ill with the elderly makes economic sense for states. As long as a nursing home's mentally ill population stays under 50 percent, the federal government will help pay for the residents' care under Medicaid. Otherwise, the home is classified a mental institution, and the government won't pay.

In Missouri, more than 4,400 younger mentally ill people are living in nursing homes, in part because of a state program that helps the elderly stay in their own homes longer.

Nursing homes "are looking at 60 to 70 percent occupancy, and the statistics tell us they've got to be in the 90s to operate successfully," said Carol Scott, the state long-term care ombudsman for 20 years. "They're going to take anybody they can."

Gaps in staff training leave the homes inept at handling the delusions and aggression of the mentally ill, said Becky Kurtz, the state long-term care ombudsman in Georgia, where nearly 3,300 younger mentally ill people live in nursing homes.

"Often they'll say, 'I hate it there. I'm angry. I don't want to be there.' Sometimes the behavioral issues are the result of being ticked off you're in a nursing home," Kurtz said.

Pat Willis of the Center for Prevention of Abuse said she has seen elderly residents terrified by younger, mentally ill residents who scream and yell, day and night. "The senior residents are afraid," Willis said. "They would prefer to sit in their rooms now and keep the doors shut."

Nursing home operators say protections against frivolous transfer or discharge keep the homes from throwing out some mentally ill residents.

"Many times, the nursing home's only option becomes dialing 911," said Lauren Shaham, a spokeswoman for the American Association of Homes and Services for the Aging.

Thursday, March 19, 2009

Need Parents to Live in the Real World

It is true that a lot of our young people are mentally ill and probably needed help at a much earlier age. I see a lot of parents who will not get the proper treatment for their children because they are in denial of the fact that their children could be diagnosed mentally ill. I know how hard it is to grasp and admit that your loved one can be mentally ill, but these young children need help early so that they don't "self medicate" and find them selves in prison in their early adulthood. Some of them are there because their parents stick their heads in the sand when a medical professional tells them their child has a mental illness and hope they will just "grow out of it". I have had parents tell me that, then several years later I hear that the child is now in juvie hall and doing in-appropriate things. We need to help these young people, and we need parents to do a better job.

The majority of juvenile offenders transferred to adult criminal courts have one or more psychiatric disorders--and they often go untreated, found a Northwestern study.

The Psycho-Legal Department at the Feinberg School of Medicine, which conducts a series of studies called the Northwestern Juvenile Project, also found that a disproportionate number of youths tried in adult courts were minorities.

Jason Washburn, who headed the study, said the juvenile system is flawed, and trying youth offenders as adults may cause more problems than it solves.

“It’s clear to see that the kids who are referred to adult courts and sent to prison end up doing much worse [mentally],” he said. “It doesn’t have any positive rehabilitation effect and it may actually be doing them some damage.”

Illinois law states the juvenile court has jurisdiction over all youths under the age of 16 unless they are transferred to adult criminal court.

There are five felony offenses for which children over the age of 13 are automatically tried in adult criminal court:
• First-degree murder
• Aggravated criminal sexual assault
• Aggravated battery with a firearm
• Armed robbery
• Aggravated vehicular hijacking committed with a firearm

Washburn said that perhaps the most disconcerting finding is the strong link between youths being tried in adult courts and the prevalence of mental illness. About 68 percent of these youths had at least one psychiatric disorder and 43 percent had two or more.

These rates have heightened the need for psychiatric care at juvenile facilities in order to help these youths as they get older and reduce their odds of repeating criminal behavior.

Tiffany Masson, a professor at the Chicago School of Professional Psychology, who researches juvenile detention centers, said adequate mental health treatment has been a problem for the Cook County juvenile justice system for a long time.

“They have had minimal mental health treatment for juvenile offenders,” she said. “They may be getting some individual therapy, but it’s not the evidence-based therapy that they need for recovery.”

Masson said this lack of treatment is a huge concern because it may cause more problems in the future.

“The juveniles with the risk factors for delinquency, if they go unaddressed, that can lead them on a pathway to behavioral issues as adults,” she said.

Washburn said clinicians could help lower the amount of at-risk youths sent to adult criminal court by “determining how psychological factors should be mitigated and which youths may respond best to alternative sentencing.” Then, he said, it is up to the correctional system to provide more mental health care for youths who are in prisons.

“Thus far, kids in detention centers who had serious mental problems like depression, mania and psychosis have been very unlikely to get any attention for their needs,” he said.

Though there is still plenty of room for improvement, Masson said there have been significant upgrades in mental health coverage at the Cook County Juvenile Temporary Detention Center over the past few years. She attributes much of that change to the increase in media coverage of the center.

“Because of the recent media attention, there’s been quite an effort to reform the center,” she said. “They’re starting to do discussion groups and apply more cognitive-behavioral therapy these days, after only doing screenings in the past.”

In addition to the large percentage of juveniles needing mental health care, the study also found that males, African-Americans and Hispanics are at greater odds of being tried in adult criminal courts than females and non-Hispanic whites.

“When factors like the type of crime are held consistent, African-Americans and Hispanics are still being sent to adult trials at a much higher rate,” Washburn said.

Washburn also thinks recent changes have improved juvenile rights in Illinois. Until 2008, juveniles arrested for selling drugs within 1,000 feet of a school or public housing were automatic sent to adult courts.

He said this law had lead to the disproportionate number of minorities being tried in higher courts, but now that it has changed, the situation should improve in the future.

“Before the drug law was changed, Illinois’s laws were probably pretty stringent compared to other states,” he said. “Now the laws that are in place are much more fair and aren’t too far off from other states.”

Monday, March 9, 2009

Could it Be?

I have heard of this, quite bizarre, but I guess diagnosable.

Can Lyme Disease Lead to Insanity, Violent Tendencies?

Can Lyme disease lead to violence, even murder?

This question has come up twice in the past month. First in the case of Travis, the chimpanzee, which mauled a woman in Connecticut. It was reported that he was suffering from the tick-borne illness and that it was either the disease itself or the medication he was taking that caused the chimp, once a star of TV commercials, to snap.

And now, the disease is being blamed for causing the mental illness of a man accused of gunning down a pastor Sunday at a suburban Illinois church.

Police did not release the gunman's name, but the St. Louis Post-Dispatch reported late Sunday that he is 27-year-old Terry Joe Sedlacek. Sedlacek’s mother said Lyme disease attacked her son’s brain and caused the psychosis that caused him to kill the pastor and wound two others. FOX News could not immediately confirm the report.

Sedlacek was reportedly taking several medications to combat Lyme disease and seizures, which nearly killed him in 2003, the paper reported.

Although the disease has been associated with mental illness, the link between Lyme disease and violence is largely unproven, said one doctor.

“Chronic Lyme disease can be associated with seizures, depression, anxiety and even psychosis has been reported,” said Dr. Marc Siegel, an internist and FOX News Channel contributor.

“It’s possible, but the problem is, something being reported doesn’t always mean it’s the cause. For example, someone may have psychosis or seizures — but Lyme disease may not be the cause — so you have to be really careful.”

The fact is that Lyme disease is very tricky.

“Determining whether Lyme disease is the cause of a related factor is the art of medicine," Siegel said. “It’s not an automatic — it depends on the case.”

Siegel told that he would actually like to see the medical records of Sedlacekto to see if psychosis is even a possibility.

“It would depend on if the person has chronic Lyme disease,” he said. “You would have to look at medical records to see when he was treated and diagnosed and to see if this is even a possibility. The key question here is whether this guy ever received proper treatment early on.”

According to the Centers for Disease Control and Prevention, Lyme disease is caused by the bacterium, Borrelia burgdorferi, which normally lives in mice, squirrels, deer and other small animals. It is transmitted among these animals — and to humans — through the bites of certain species of ticks.

Connecticut, New Jersey, Pennsylvania and upstate New York all have high rates of Lyme disease. The culprit in the Northeast is the deer tick. In the Pacific coast, the disease is spread by the western-black legged tick.

Signs and Symptoms:

— A very pronounced round, red rash that spreads at the site of the bite

— Flu-like symptoms

— Fatigue

— Headaches

— Sore muscles and joints

— Fever


If you have early-stage Lyme disease, oral antibiotics such as doxycycline, amoxicillin, or cefuroxime axetil are most often prescribed. According to the National Institutes of Health, studies have shown that most patients can be cured within a few weeks of taking these drugs.

But if it goes untreated, Lyme disease can lead to serious health problems.

According to the Mayo Clinic, those problems include:

— Chronic joint inflammation (Lyme arthritis), particularly of the knee

— Neurological symptoms, such as facial palsy and neuropathy

— Cognitive defects, such as impaired memory

— Heart rhythm irregularities

— Memory loss

— Difficulty concentrating

— Changes in mood or sleep habits

Click here to find out how you can avoid getting bitten by a tick.

The Associated Press contributed to this report.

* See Next Story in Health

Tuesday, March 3, 2009

Just Common Sense

This is a nice article to read even though the information is not necessarily new. I was told a lot of years ago that my mother's bipolar illness was definitely an inherited trait. My great-grandmother died in an "insane asylum" in Louisiana. But neither myself nor my two brothers were ever diagnosed as bipolar. I am glad to hear that some children and young adults are getting help early for their mental illnesses.

Pitt Study Finds Children Of Bipolar Parents Have Increased Risk Of Psychiatric Disorders

An estimated one in 100 children and teens worldwide has bipolar disorder. Identifying the condition early may improve long-term outcomes, potentially preventing high psychosocial and medical costs. Researchers from the Pittsburgh Bipolar Offspring Study suggest that having family members with bipolar disorder is the best predictor of whether their children will go on to develop the condition.

"A bipolar diagnosis at a young age deprives children of the opportunity to experience normal emotional, cognitive and social development, and this is why there is an urgent need to identify, diagnose and treat these patients early on," said Boris Birmaher, M.D., director of the Child and Adolescent Anxiety Program and co-director of the Child and Adolescent Bipolar Services at Western Psychiatric Institute and Clinic of UPMC, endowed chair in Early Onset Bipolar Disease and professor of psychiatry at the University of Pittsburgh School of Medicine.

Compared with the offspring of control parents, children with bipolar parents had a 14-fold increased risk of having a bipolar spectrum disorder, as well as a two-to three-fold increase of having a mood or anxiety disorder. Children in families where both parents had bipolar disorders also were more likely to develop the condition than those in families containing one parent with bipolar disorder. However, their risk for other psychiatric disorders was the same as children who had one bipolar parent.

Bipolar disorder, commonly called manic-depression, often emerges in adolescence, and is characterized by intense swings between depression, mania and periods with mixed symptoms. Bipolar spectrum disorders consist of three sub-types. Bipolar I (BP-I) is characterized by episodes of full-blown mania and major depression; bipolar II (BP-II) involves episodes of less severe mania, called hypomania, and major depression; and the third sub-type is called Bipolar Not Otherwise Specified (BP-NOS), which involves symptoms consistent with elated or irritable moods that are disruptive to daily living, plus two to three other symptoms of bipolar disorder.

In this blind study, researchers compared 388 children and teens, ages 6 to 18, of 233 parents with BP-I and BP-II to 251 offspring of 143 demographically matched control parents. Parents were assessed for psychiatric disorders, family mental health history, family environment, exposure to negative life events, and also were interviewed about their children. Children were assessed directly for bipolar disorder and other psychiatric disorders by researchers who did not know their parents' diagnoses.

"Consistent with prior research, most parents with bipolar disorder recalled that their illness started before age 20 and about 20 percent had illness that started before age 13," said Dr. Birmaher. "In contrast, most of their children developed their first bipolar disorder episode before age 12, suggesting the possibility that parents were more perceptive of their children's symptoms early in life or perhaps that bipolar disorder appears earlier in new generations."

The researchers note that these findings have important clinical implications. "Clinicians who treat adults with bipolar disorder should question them about their children's psychopathology to offer prompt identification and early interventions for any psychiatric problems that may be affecting the children's functioning, particularly early-onset bipolar disorder," said Dr. Birmaher. "Further studies are needed to help determine the clinical, biological and genetic risk factors that may be modified to prevent the development of psychiatric disorders in the children of those with bipolar disorder."