MENTAL HEALTH NEWSTM YOUR TRUSTED SOURCE OF INFORMATION, EDUCATION, ADVOCACY AND RESOURCES WINTER 2004 FROM THE LOCAL, STATE, AND NATIONAL NEWS SCENE VOL. 6 NO. 1

nors s Ho n HNew ciatio M o n Ass erica ogy Am cidol Sui 1 of age 1 Understanding and Coping With Suicide See P

National Institute of Mental Health by five to three. It has been estimated people who kill themselves have depres- Adverse life events in combination Washington, DC that there may be from eight to 25 at- sion or another diagnosable mental or with other risk factors such as depression tempted suicides per every one suicide substance abuse disorder, often in com- may lead to suicide. However, suicide uicide is a tragic and potentially death. The alarming numbers of suicide bination with other mental disorders. and suicidal behavior are not normal preventable public health prob- deaths and attempts emphasize the need Also, research indicates that alterations responses to stress. Many people have lem. In 2000, suicide was the for carefully designed prevention efforts. in neurotransmitters such as serotonin one or more risk factors and are not sui- S 11th leading cause of death in Suicidal behavior is complex. Some are associated with the risk for suicide. cidal. Other risk factors include: prior the United States. Specifically, 10.6 out risk factors vary with age, gender and Diminished levels of this brain chemical suicide attempt; family history of mental of every 100,000 persons died by sui- ethnic group and may even change over have been found in patients with depres- disorder or substance abuse; family his- cide. The total number of suicides was time. The risk factors for suicide fre- sion, impulsive disorders, a history of tory of suicide; family violence, includ- 29,350, or 1.2 percent of all deaths. Sui- quently occur in combination. Research violent suicide attempts, and also in ing physical cide deaths outnumber homicide deaths has shown that more than 90 percent of postmortem brains of suicide victims. see NIMH on page 26 Providing Hope on the Subject of Depression and Suicide: A Documentary Filmmaker’s Personal Journey

By Liisa K. Hyvarinen gate complex news stories, exposing his Freelance Journalist own illness could have been career sui- cide. But “coming out of the closet” et me begin my story with an about his depression – as Wallace jok- excerpt from an interview I did ingly called it – had not been a devastat- in May of 2000 with CBS ing experience for him. Quite the con- News 60 Minutes correspon- trary. Ldent Mike Wallace, for my documentary, As we wrapped up the interview and “Silent Screams.” Wallace stood up to leave I wished my

Wallace: Depression...there was a own father could have heard this news legend’s encouraging words. stigma attached to depression. You're a little mentally crazy or something like ****** that sort and you don’t want to acknowl- “Wake up, sweetie,” I could hear my edge that and so I didn’t want to ac- mother saying very softly. “I need you to knowledge it and nobody in the office get up. I need to tell you something,” she knew. (Laughing) They knew I was added quietly but even through my sleep strange but I’ve always been strange so I could tell from her tone of voice some- they figured what the dickens Mike is thing was wrong. Rubbing my eyes like just a little more difficult than usual. any other 14-year-old at six o’clock in Hyvarinen: Some people say that you the morning I looked up and saw my can just snap out of it? mother sitting on the edge of my bed. photo courtesy: Silent Screams She looked tired but as she reached out Wallace: You cannot snap out of it. You CBS News 60 Minutes correspondent Mike Wallace discusses the stigma cannot. I mean pull yourself up come on to run her fingers through my hair and I used to think come on, Mike, don’t of mental illness during his interview for the documentary Silent Screams pat me on the cheek her motions seemed pamper yourself, you’ve got the blues, frozen almost robot like. I looked up and you’ve had the blues before, get out of it. And lots of people have come out of the personal battles with suicidal thoughts asked: “What’s wrong, Mom?” And my It isn’t the blues. It’s something much closet (laughs) out of the closet about it when I was preparing a five-part TV mother uttered what she has told me later deeper than that. (depression). People of some accom- news series and documentary titled on were the hardest words she ever had plishment. And they say the worst thing “Silent Screams” about that subject mat- to tell me. “Your father is no longer Hyvarinen: In the beginning you chose you can do is to feel ashamed of it. You ter. Wallace had first been diagnosed here. He died last night while you were not to tell people. wouldn’t be ashamed if you had Scarlet with depression in the early 1980s and asleep.” Wallace: That’s right. I was not going to Fever or if you had a cold or if your ap- hearing his candid remarks resonated It was February 1983. My father, who tell anybody. pendix burst. Truly this is simply an ill- with me. I could understand why he had had battled clinical depression for years, ness. And you get over it. tried to conceal his condition because of had taken his own life. A son, a husband Hyvarinen: Why? the stigma associated with mental ill- and a father of three, my father was also ****** Wallace: Because you feel as though ness. For a successful and respected an accomplished scientist and a man this man turned into a nut case. There’s Mike Wallace sat down with me for newsman whose entire career was based who loved to entertain and tell jokes. this stigma. It shouldn’t be anymore. an interview about his depression and his on his quick brain and ability to investi- see Journey on page 16

NON PROFIT Mental Health News Education, Inc. ORGANIZATION 65 Waller Avenue U.S. POSTAGE PAID White Plains, NY 10605 WHITE PLAINS, NY PERMIT NO. 153 PAGE 2 MENTAL HEALTH NEWS ~ WINTER 2004 MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 3 PAGE 4 MENTAL HEALTH NEWS ~ WINTER 2004

Mental Health News Advisory Council

Hon. Tom Abinanti Michael B. Friedman, C.S.W. Andrew P. Levin, M.D., Medical Director Joseph F. Ryan, Ph.D., Dean Westchester County Legislature - 12th District Public Policy Consultant Westchester Jewish Community Services PACE University School of Public Administration

Sigurd H. Ackerman, M.D., President & Medical Director Steven J. Friedman Robert M. Lichtman, Ph.D., DAPA Thomas E. Sanders, C.S.W., President & CEO Silver Hill Hospital Mental Health & Public Policy Analyst Rockland Psychiatric Center Family Service of Westchester

Nadia Allen, Executive Director Alfred A. Fusco, Executive Director Constance Lieber, President, Board of Directors Phillip Saperia, Executive Director Mental Health Association in Orange County Mental Health Association in Onondaga County NARSAD Coalition of Voluntary Mental Health Agencies

Richard Altesman, M.D., Representative Kenneth M. Glatt, Ph.D., Commissioner Robert Litwak, C.S.W., Assistant Executive Director Jennifer Schaffer, Ph.D., Commissioner American Psychiatric Association National Assembly Dutchess County Department of Mental Hygiene Mental Health Association of Westchester Westchester County Department of Community Mental Health

Gene Aronowitz, Ph.D., Director of Operations Joseph A. Glazer, President & CEO Hon. Nita M. Lowey Jack C. Schoenholtz, M.D., L.F.A.P.A., Medical Director Fordham-Tremont Community Mental Health Center Mental Health Association In New York State U.S. Congress - 18th District Rye Hospital Center

Peter C. Ashenden, Executive Director J.B. Goss, R.Ph., Ph.D. Paige Macdonald, Executive Director Judy L. Scheel, Ph.D., Director Mental Health Empowerment Project J.B. Goss & Company Families Together in New York State Center for Eating Disorder Recovery

Hon. Chris Ashman, M.S., Commissioner Arnold Gould, Co-President Frank A. Marquit, CEO - President Edythe S. Schwartz, A.C.S.W., Executive Director Orange County Department of Community Mental Health NAMI Queens/Nassau National Artists for Mental Health, Inc. Putnam Family & Community Services

Alan D. Barry, Ph.D., Administrative Director, Flemming Graae, M.D., Chief, Child & Adolescent Randall Marshall, M.D., Associate Professor of Clinical J. David Seay J. D., Executive Director Department of Psychiatry, Norwalk Hospital Psychiatry, Westchester Medical Center Psychiatry, New York State Psychiatric Institute NAMI - New York State

Jeannine Baart, M.S. Steven Greenfield, Executive Director Hon. Naomi C. Matusow Janet Z. Segal, C.S.W., Chief Operating Officer Mental Health Education Consultant Mental Health Association of Nassau County New York State Assembly - 89th District Four Winds Hospital

Alfred Bergman, Chief Executive Officer Ralph A. Gregory, President & CPO Richard H. McCarthy, Ph.D., M.D., C.M. Kren K. Shriver, M.P.H., M.D., Clinical Director Supervised Lifestyles United Way Of Westchester & Putnam Comprehensive NeuroScience Hudson River Psychiatric Center

Sheldon Blitstein, C.S.W. Mary Guardino, Founder & Executive Director Steven Miccio, Executive Director Michael Silverberg, President NY United Hospital - Behavioral Health Services Freedom From Fear PEOPLe NAMI - New York State

James Bopp, Executive Director Mark D. Gustin, M.B.A., MPS, Senior Associate Director David H. Minot, Ithaca College, Chairman Alan B. Siskind, Ph.D., Executive Vice President & CEO Rockland and Middletown Psychiatric Centers Kings County Hospital Center Mental Health News - University Advocacy Division Jewish Board of Family and Children’s Services

Linda Breton, C.S.W., Assistant Executive Director Mary Hanrahan, Government Relations Specialist Grant E. Mitchell, M.D., Director, Mental Health Services Steven H. Smith, Psy.D., Consulting Psychologist Westchester Jewish Community Services New York Presbyterian Hospital The Mount Vernon Hospital Grace Church Community Center

David Brizer, M.D. Dean B. Harlam, M.D., Associate Medical Director Margaret E. Moran, CSW, VP, Administrative Services Jeffery Smith, M.D. Author and Private Practitioner Saint Vincent’s Behavioral Health Center - Westchester Behavioral Health Services - St. Vincent’s Catholic Medical Centers Private Practice - Scarsdale, NY

David S. Brownell, Commissioner Carolyn S. Hedlund, Ph.D., Executive Director Meryl Nadel, D.S.W., Chairwoman Andrew Solomon, Contributing Writer, Magazine Onondaga County Department of Mental Health Mental Health Association of Westchester Iona College - School of Social Work The New York Times

Jacqueline Brownstein, Executive Director Rhona Hetsrony, Executive Director Sarah Newitter, Executive Director Hon. Nicholas A. Spano Mental Health Association in Dutchess County North Shore LIJ Health System - Zucker Hillside Hospital NAMI of Westchester, Inc. New York State Senate - 35th District

John F. Butler, Manager of Community Affairs Richard S. Hobish, Esq., Executive Director Evelyn J. Nieves, Ph.D., Executive Director Hon. Andrew J. Spano Verizon - New York Pro Bono Partnership Fordham-Tremont Community Mental Health Center Westchester County Executive

Alison Carroll, C.S.W., Director of Day Treatment Marsha Hurst, Ph.D., Director, Health Advocacy Program Terri M. Nieves, MS.Ed, M.S., Director of Counseling Services Giselle Stolper, Executive Director Putnam Family & Community Services Sarah Lawrence College Mercy College Mental Health Association of New York City

Amy Chalfy, C.S.W., Bronx District Director Doug Hovey, Executive Director Megan Nowell, Director Harris B. Stratyner, Ph.D., C.A.S.A.C., Director JASA Independent Living Center of Orange County Mental Health Association of Putnam County NYPH & UHC Chemical Dependency Program

Steven K. Coe, Executive Director Beth Jenkins, Executive Director Karen A. Oates, D.S.W., President & CEO Jeannie Straussman, Director, Central NY Field Office Community Access Mental Health Association in Tompkins County Mental Health Association of Rockland County New York State Office of Mental Health

George M. Colabella, President Tom Jewell, Ph.D. Hon. Suzi Oppenheimer Timothy B. Sullivan, M.D., Clinical Director Colabella & Associates Family Institute for Education Practice and Research New York State Senate - 36th District Saint Vincent’s Behavioral Health Center - Westchester

Robert S. and Susan W. Cole Sabrina L. Johnson, B.A., Recipient Affairs Liaison Matthew O’Shaughnessy, Senior Vice President Janet Susin, Co-President Cole Communications Westchester County Department of Community Mental Health WVOX & WRTN Radio NAMI Queens/Nassau

Marianne Coughlin, Administrator Rami P. Kaminski, M.D., Medical Director of Operations Ellen L. Pendegar, M.S., R.N., C.S., CEO Richard P. Swierat, Executive Director New York-Presbyterian Hospital Westchester Division New York State Office of Mental Health Mental Health Association In Ulster County Westchester ARC

Anthony A. Cupaiuolo, Director John M. Kane, M.D., Chief of Psychiatry Barry B. Perlman, M.D., Chief of Psychiatry Maria L. Tiamson, M.D., President Michaelian Institute - PACE University Hillside Hospital St. Joseph’s Hospital - Yonkers Psychiatric Society of Westchester

Joseph Deltito, M.D., Clinical Professor of Psychiatry and Ron Kavanaugh, Executive Director Susan Perr, M.A., Mental Health Advocacy Coordinator Alan Trager, Executive Director & CEO Behavioral Science, New York Medical College Search For Change WILC - Mental Health Advocacy Project Westchester Jewish Community Services

Anthony B. DeLuca, ACSW, Commissioner James J. Killoran, Executive Director Cynthia R. Pfeffer, M.D., Professor of Psychiatry Anthony F. Villamena, M.D., Chief of Psychiatry Tompkins County Mental Health Services Habitat For Humanity - Westchester Weill Cornell Medical College of Cornell University Lawrence Hospital Center

Frank DeSiervo, ACSW, Division Chief, MH Services Samuel C. Klagsbrun, M.D., Executive Medical Director Hon. Michael J. Piazza, Jr., Commissioner Jonas Waizer, Ph.D., Chief Operating Officer Dutchess County Department of Mental Hygiene Four Winds Hospitals Putnam County Department of Mental Health FEGS - Behavioral & Health Related Services

Steve Dougherty, Executive Director Marge Klein, Executive Director Premkumar Peter, M.D., Medical Director Joyce Wale, Assistant Vice President - Behavioral Health Laurel House The Guidance Center Putnam Hospital Center - Mental Health Services New York City Health & Hospitals Corporation

Toni Downs, Executive Director Lee-Ann Klein, M.S., R.D., Nutritionist James R. Regan, Ph.D., Chief Executive Officer Maralee Walsh, Ph.D., Program Director-Behavioral Health Center Westchester Residential Opportunities Albert Einstein College of Medicine Hudson River Psychiatric Center Westchester Medical Center

Douglas Drew, Consumer Link Advocate Easy Klein, Media Coordinator Starr R. Rexdale, M.D., Medical Director Mary Ann Walsh-Tozer, Commissioner Mental Health Association of Nassau County NAMI - New York Metro Division The Guidance Center Rockland County Department of Mental Health

Denneth J. Dudek, Executive Director Andrea Kocsis, C.S.W., Executive Director Lisa Rattenni, Vice President, Behavioral Health Services Michael Wein, CSW-R, CASAC, Administrator Fountain House Human Development Services of Westchester Westchester Medical Center NY United Hospital - Behavioral Health Services

Barbara Finkelstein, Esq., Executive Director Joshua Koerner, Executive Director John Rock, Consumer Liaison Peter Yee, Assistant Executive Director Westchester - Putnam Legal Services Choice Hudson River Psychiatric Center Hamilton-Madison House

Rena Finkelstein, President Lois Kroplick, M.D., Founder & Chairwoman Evelyn Roberts, Executive Director Neil Zolkind, M.D., Clinical Director NAMI-FAMILYA of Rockland County Mental Health Coalition of Rockland County NAMI - New York City Metro Westchester Medical Center - Behavioral Health Center

Donald M. Fitch, MS., Executive Director Rabbi Simon Lauber, Executive Director Harvey Rosenthal, Executive Director Mental Health News expresses its deep appreciation The Center For Career Freedom Bikur Cholim of Rockland County NYAPRS to our Advisory Council for their guidance and support.

Pam Forde, Director Joseph Lazar, Director, NYC Field Office L. Mark Russakoff, M.D., Director of Psychiatry committee in formation Putnam Family Support and Advocacy, Inc. New York State Office of Mental Health Phelps Memorial Hospital Center MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 5 Table of Contents

The News at Mental Health News: continued Publisher’s Desk 28 Chairman Announces Bristol-Myers Squibb Grant 6 Suicide “Sucker-Punch” 28 Campaign 2003 Raises Vital Funds for MHNews 7 Editorial to The Publisher: “Suicide by Cop”

Columns NewsDesk 17 The NAMI-NYS Corner: The View From Albany 8 HHS Announces Medicare Rates 18 A Voice of Sanity: Collaboration Not Coercion 8 Wellstone Anniversary: Parity Still Awaits 19 Point of View: Preparing for the Elder Boom 9 Mutant Serotonin Gene Linked to OCD 20 The NARSAD Report: The Warning Signs of Suicide 9 Smoking Reduces MAO Levels Outside of Lungs 21 The NYSPA Report: Gay, Lesbian and Bisexual MH 10 Supported Employment Hudson Valley Style 22 The MHA Connection: Mental Health at Crossroads 10 Columbia Researchers Present at MHA Event 23 Working With Medications: Do Meds Make Us Fat? Special Suicide Issue Articles of Interest 1 NIMH: Understanding and Coping With Suicide 29 Four Winds Hospital’s Fall Supplement 1 Documentary Filmmaker’s Personal Journey 33 NYC Moves Beyond Freedom Commission Report 11 Salute to the American Association of Suicidology 37 Where Do Our Democratic Candidates Stand on MH 12 Predicting Suicide: Dilemma for Treating MD 43 Courage to Speak: Addressing Drug Prevention 15 Thinking About Suicide ? Read This First 44 Hall-Brooke President Urges Focus on Children 22 Lessons Learned After Suicide 52 Losing Weight: It’s A Mind Thing 27 Depression and Suicide: An Eastern Perspective 53 Internet Dating Site for People With Mental Illness 27 Helping Families Heal from Suicide 34 Children Bereaved by the Suicide of a Loved One Thanks to Our Advertising Sponsors 36 Co-Occurring Disorders and Suicide Risk SLS Health, J.P. Morgan Chase and Company , MHA of Westchester 38 Early Detection and Intervention Offers Lifeline New York-Presbyterian Psychiatry, CHOICE of New Rochelle, NARSAD 40 Suicide and Older White Men New York State Psychiatric Association, MHA of Nassau County Four Winds Hospital, Institute for Community Living, FEGS 42 AFSP Completes College Film on Suicide Jewish Board of Family and Children’s Services, NoLongerLonely.com 46 Suicide Services in Connecticut Saint Vincent Catholic Medical Centers—Behavioral Health 46 Managing the Acutely Suicidal Patient MHA of New York City, Hall-Brooke Behavioral Health Services 47 Academic Interest in Suicide Becomes Personal Norwalk Hospital—Department of Psychiatry, Silver Hill Hospital Family Service of Westchester, The Guidance Center 48 Why Do People Kill Themselves ? Association of Behavioral Healthcare Management—New York Chapter 50 Suicide: An Addictive Behavior MHA of Rockland County, Putnam Family Support and Advocacy 51 Youth Suicide: Outreach Builds Bridges Westchester Residential Opportunities, Search for Change 52 Suicide and Mental Illness: A Commentary Human Development Services of Westchester, MHA in Putnam County NAMI of Westchester & Rockland, The Psychiatric Society of Westchester The News at Mental Health News The Center for Career Freedom, Phelps Memorial Hospital Center Putnam Family & Community Services, Westchester Jewish Community Services 28 Verizon NY Employees Can Now Pick MHNews Westchester Medical Center—Behavioral Health Center PAGE 6 MENTAL HEALTH NEWS ~ WINTER 2004 The Publisher’s Desk

strike 20% of the population—that is one parent, a teacher, a husband or wife, a Isn’t suffering from a psychic disor- Suicide in five persons will at some time in their son or daughter, a doctor, a lawyer or a der such as depression quite enough to “Sucker-Punch” life, experience some form of mental candlestick maker. deal with? Thoughts and acts of suicide illness. Nobody can say exactly, when and serve as a “low blow” for victims to By Ira H. Minot, Publisher Mental illness, by its very nature, why a psychic disturbance takes hold of have an even chance at weathering the and Founder, Mental Health News poses a nasty conundrum for everyone a person. All we know is that it does. storm. That’s the unexpected suicide involved. The players include the pa- We notice something is not right or they sucker-punch. tient (consumer) presenting symptoms, tell us that they are not feeling right. The statistics as reported by the his or her loved ones (and employer per- Imagine for a moment, that you are American Foundation for Suicide Pre- haps), and the treatment professional going through your normal daily routine vention at www.afsp.org make this fact who will be seen to treat the case. Lets at home, work or school and suddenly a perfectly clear. look at them in reverse order. strange and totally foreign feeling comes The treatment professional be they a over you. It may perhaps be isolated to a • More than 29,000 people in the Psychiatrist, Psychologist, or Psychiatric part of your body such as your abdomen, United States kill themselves every Social Worker, should have the neces- limbs, chest or head or a full body feel- year. sary skill and experience to diagnose the ing. You may not even know how to problem. However, the diagnosis and describe what it is exactly you are feel- • Suicide is the 11th leading cause of treatment of mental illnesses is fraught ing, but it doesn’t feel normal. You may death in the U.S., accounting for 1.3% of all deaths. with challenges and very often takes feel tired or too energetic, too slow in months or perhaps years to correct. The thinking or have thoughts racing into • A person dies by suicide about presenting symptoms may be at their your head at an abnormally high rate of every eighteen minutes in the U.S. earliest stages of the patient’s problem or speed. You may feel like you’re having An attempt is made an estimated may be presented as a sudden or recur- a heart attack because there is a pound- once a minute. ring full blown episode. In addition, the ing in your chest, or you are hearing or patient’s age, education, financial re- seeing things that you have never en- • There are more than four male sui- sources (including health insurance) and countered. You hope that it’s just a cides for every female suicide. support network may detract from or passing fever, but when it happens again However, at least twice as many females as males attempt suicide. improve the eventual outcome. Finally, tomorrow, you get scared and a sense of Ira H. Minot, CSW the type of presenting symptoms may gloom or panic may begin to invade your • Every day, approximately eighty-six heighten the fear and confusion within usual demeanor and sense of self. Americans take their own life, and the world surrounding the patient, which You may have tried to hide the fact 1500 attempt. There are an esti- increases the difficulty they have in cop- that you’re not yourself, but people mated eight to twenty-five at- epressing circumstances cer- ing with day to day existence. around you start to notice and question tempted suicides to one completion. tainly come in all shapes and Suicide, a thought that may have your condition. It’s a hard thing to ex- sizes. Difficulties in the never before entered a person’s vocabu- plain to people, and you may not even What more can be said? I myself arena of love and relation- lary, may suddenly appear as a result of have anyone that you can turn to. What have been down this dark and dangerous Dships, careers, financial situations and the sudden confusion and pain inflicted do you do? road—so I know it happens and it defies all of the different ways people measurer by their psychic difficulties. Many people go alone or are brought comprehension or description. their self worth can’t help but leave us Loved ones, friends and employers to the doctor or an emergency room by a What I will say and plead to anyone feeling vulnerable at some time in our play an important role in the typical sce- friend or family member. In most cases, who finds themselves in such a dark and lives. nario of mental illness. They may help a heart attack is quickly ruled out, and dangerous place is this: whatever you are For some, life’s disappointments in- the situation by providing unconditional you are told you are depressed or are feeling right now is not your fault but flict deeper psychic wounds then in oth- emotional support, concrete direction having an anxiety attack. In many cases rather an illness that is treatable. Please ers. Since September 11th we have be- towards help, and convalescent care. you are given time off for a few days of understand that this storm will eventu- come more open to and aware of the fact However this typically is the exception rest, perhaps given a mild tranquilizer or ally pass, and that you must continue to that emotional disturbances can lead to rather than the norm. In many cases well anti-anxiety medication and the storm try to find the help that you need. more serious outcomes and that none of intentioned friends and family may actu- passes. Perhaps it passes for a period What you may not realize is that there us are immune. ally make the situation worse. In some only to reappear with more intensity. are programs and services within the When it comes to our physical health, instances their inability to understand You may not have taken this occurrence mental health community near you. situations are more openly discussed, that the patient may be in harms way seriously. You throw the medications Here at Mental Health News, our mis- less stigma exists, and ample supports quickly becomes a critical factor. Since away due to their side-effects and impli- sion is to provide you with a source of are provided when a problem arises. employers may be the sole source of cation that you are a crazy person. In information, education, advocacy and In some dark and protected place financial resources for the patient, they many cases the stigma of having a men- recourses. Our worst enemy is fear, within us all is the dread that our next pose an enormous threat to a positive tal problem caused you to deny its exis- which stems from a lack of education annual physical will disclose a lump that prognosis and final outcome. More of- tence—hoping that it was just a fluke. and understanding of mental illness. needs further examination, or an unusual ten than we would hope, many employ- Mood disturbances, be they elevated Suicide rates have declined in some finding in our routine blood test. With ers are quick to terminate people suffer- or depressed cause many people to with- areas within the last 5 years—suggesting luck and good medicine, our prognosis is ing with a mental illness. draw from their normal activities of life. that aggressive educational campaigns hopefully better than we probably imag- The positive side to this investigation, Many try to self medicate with drugs or and the kinds of programs and services ine. That is due in part to a billion dollar which I will address in a moment, are the alcohol. Staying in bed for longer peri- that are featured in this issue of Mental medical industry that continues to make many programs and services available ods of the day and avoiding contact with Health News are making a difference. groundbreaking discoveries in diagnostic within the mental health community people may provide transient relief but We are in the midst of the holiday equipment and treatment procedures that surrounding the patient. Unfortunately quickly add to the downward spiral of a season, which can be a most difficult have turned the corner on many previ- this world may not be known to the pa- mental illness if continued for a long time for many who battle mental ill- ously deadly diseases. tient, or be promoted by the profession- period of time. Since mental illnesses nesses. I urge you to reach out to those Unfortunately when it comes to grap- als treating the individual. are so varied, the treatments given may around you in need. Become a volunteer pling with a disorder of the mind, the First and foremost, the patient is a not immediately solve the problem. and get involved in supporting organiza- playing field is not quite as level. Since person, not a case history or a medical Typically, a combination of medication tions in your community such as the maladies such as schizophrenia, anxiety reimbursement category. They have a and talk therapy are applied to arrest the Mental Health Association (MHA) and disorders and depression do not show up life, they have feelings, and most cer- problem. Unfortunately, this is not an the National Alliance for the Mentally Ill in a simple blood test, seen on a common tainly they have hopes and dreams. exact and problem-free science. Weeks (NAMI). Remember, mental health is x-ray, or further investigated with an They may be a child or an adolescent at may pass while various medications are about us all, and you can make a differ- MRI, their cause, degree, and future the doorstep to a future filled with glee- tried. Unless the patient is vigorously ence in someone’s life. course present a mystery and relative ful anticipation. They may be a young monitored, serious downward spirals in puzzle waiting to be solved. adult building an education for their role the form of hopelessness and pain lead Have A Great Winter ! But the fact is, that mental illness will as a productive adult. They may be a many to thoughts of suicide. Ira H. Minot, CSW MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 7 Editorial to The Publisher

tory as the "signature" event of it's type. the increase in New Zealand, Australia, do not receive adequate care as it might Suicide By "Cop" Both boys were members of a group who the United States and around the world adversely effect the bottom line of an And Related wore long black trench coats to school where it has been adequately studied. insurance company or state mental and appeared to be known by many as An ever increasing trend seems to be that health facility. So the first prong of Sociocultural Phenomena angry and troubled. a subgroup of suiciders decide to take a dealing with these situations is to iden- I could list many more similar inci- bunch of others with them. The victims tify those at risk and treat any formal An Editorial dents which unfortunately are too famil- are most often the very people who psychiatric illness vigorously. The next By Joseph A Deltito M.D. iar to you now reading this article. teased and bullied them in school or be- prong might be more difficult. When watching TV and there is an ur- littled them in places of employment. Many would say our society is in gent news override of the ongoing pro- The “Post Office” remains an interesting decline, I certainly would be among gramming, if the initial scene is a school microcosm as many individuals are em- them. There are many things I as a psy- or post office, do not most of us think: ployed there in relative isolation with a chiatrist can learn through an under- “It has happened again.” In fact the very direct and at times severe chain of standing of the “POP” culture as it both term, “Going Postal” has now entered command over them. The work fre- reflects and effects the general popula- the everyday vernacular to describe quently attracts those who are otherwise tion. I think there is an important lesson someone who seems to wantonly shoot loners and may become over invested in that can be learned through the recent up his place of employment or school. their jobs. A uniform can sometimes popularity of so-called “Reality” TV These are generally portrayed by the reinforce the sadistic pettiness of bosses shows. Personality traits and question- media and spoken of as homicides, and a recipe for disaster can be placed on able behavior that previously might have surely there is justification for doing so. a slow boil. All it takes is being passed been seen to exist only in a small per- What I submit is that similar incidents over for promotion, not allowed a holi- centage of the population is now exalted are better understood, and more properly day off, a reprimand for an unclean uni- as normative behavior: that is in referred to as elaborate Suicides as the form and a person, if also suffering from “delighting” in the misfortunes and ridi- perpetrators rarely expect to live through depression or psychosis, may go boiling cule of others. Whom gets voted off the the day. They are often “neutralized” by over into mayhem. island to the survivors delight is unfortu- policemen at the scene: Suicide by Cop. Clearly, most individuals with even nately being played out in almost every It is an important distinction to make the most severe and persistent forms of high school in America. A group gets between suicide and homicide as each psychiatric illness are of no danger to the defined who sets the standards for who has its own epidemiology and treatments general public. Yet it would be untrue to belongs and who can be jettisoned from (Interventions). It is of the utmost im- say that of those who commit such vio- their small clique or society: too fat, Joseph A. Deltito, M.D. portance for we as a society to under- lent crimes do not suffer in most cases you’re out...parents not rich, you’re out... stand these situations so they can be from legitimate illnesses. In this country talk with an accent, you’re out...etc., etc., aborted and avoided. In general the ele- there appears to be a growing mentality, etc. We are becoming a less inclusive ments are these. The perpetrator or per- especially in our public schools, for society and delighting in our Survivor- n December 26, 2000 in the petrators are usually marginalized from teachers, counselors and administrators hood, until of course it is us that is ex- usually quiet Boston Suburb the mainstream culture or subculture, not to “confront” obviously troubled kids cluded, marginalized or just plain of Wakefield, Massachusetts they suffer from some formal psychiatric who may be telegraphing their distress “kicked-out.” I think we need to set a O Michael McDermott an em- illness, they feel bullied or unfairly through the clothing and grooming they better standard for our children to be ployee at an Internet consulting firm picked upon and they do not receive choose and the “bad” behaviors that may kinder to other children. At a recent proceeded down a hallway with a rifle, adequate psychiatric treatment. They demonstrate. From a public health point conference at my daughter's school I shotgun and a pistol in his hands. After may suffer from the types of personali- of view what is necessary is to identify heard the discussant say: “You can't leg- the next 7 minutes passed 7 of his co- ties which leave them feeling a shallow and treat the subset at risk. Fears still islate kindness,” when asked about how workers and bosses were shot dead. He sense of their own self-importance. persist in schools and other settings to parents should handle their children ex- then sat among the bloody bodies and In the Canterbury Suicide Project, not “label” children with Psychiatric cluding others (non-desirables) from awaited the SWAT team dispatched to conducted by Professor Annette diagnoses, yet to not do so in the face of play, parties, cafeteria tables, etc. Yet if the scene. In this case they did not kill. Beautrais and colleagues at the Christ- bonefide signs and symptoms of distress we can not legislate kindness what can His words to the police, “I don't speak Church School of Medicine in New Zea- is criminal to the child and our culture. we do as parents to ease the suffering of German.” He is later convicted of these land, extensive analyses was performed The Michael McDermotts of the world those who one day may feel “my life is crimes despite a vigorous defense which on all serious suicide attempts in youths are generally known to those around no longer worth living, and by the way I included several Psychiatrists who offer on the South Island of New Zealand. them as disturbed well before their will take a few of you with me.” testimony that he is Schizophrenic and Many important findings have emerged crimes are committed. Increasingly in depressed. It is on record that he has from the psychological autopsies they the age of Managed Care and HMO’s Joseph A. Deltito, M.D. is a Clinical made at least one suicide attempt in the performed in this study. Clearly in the less and less experienced practitioners Professor of Psychiatry at New York past. Medical College and has an office prac- th case of those who attempt (many of are used for evaluating our children in On the 110 anniversary of the birth whom completed) suicide most were need; general practitioners and social tice for psychopharmacological consul- of Adolph Hitler, April 20 1999, two known to the system as troubled indi- workers are used as psychiatric screeners tations and forensic psychiatry in Green- teen age boys, Eric Harris and Dylan viduals, most with apparent psychiatric instead of seasoned well trained Child wich, Connecticut. He is a frequent con- Klebold leave 13 dead in a Littleton, illness, particularly Depression. Their and Adolescent Psychiatrists. Even tributor to Court TV. Dr. Deltito serves Colorado high school. The name Col- schools, families and doctors clearly saw when the potentially “Postal” individuals on the Clinical Advisory Board of Men- umbine High School will live on in His- them at risk. Youth suicide has been on are identified, more often than not they tal Health News.

see page 59 for subscription and advertising information Mental Health News TM call us from 9-5 (M-F) at (914) 948-6699 or E-mail us at [email protected], and visit our website is a publication of Mental Health News Education, Inc., www.mhnews.org

a tax-exempt, not-for-profit organization. Mental Health News does not endorse the views, products, or 65 Waller Avenue, White Plains, New York 10605 services contained herein. No part of this publication may be

reproduced in any form without written permission. Ira H. Minot, C.S.W., Founder & Publisher Mental Health News is not responsible for omissions or errors. Copyright © 2003 Mental Health News Education, Inc., All rights reserved.

PAGE 8 MENTAL HEALTH NEWS ~ WINTER 2004

MENTAL HEALTH NEWSDESK

Department of Health and Human Services Announces Medicare Premium and Deductible Rates

Dept. of Health and Human Services Medicare spending and Medicare premi- per day payment for days 61 through 90 Washington, DC ums affordable as well as help us down was $210, and $420 for beyond 90 days. the road to preserving Medicare for fu- For beneficiaries in skilled nursing fa- ture generations." cilities, the daily co-insurance for days he Department of Health and Most Medicare beneficiaries enrolled 21 through 100 will be $109.50 in 2004, Human Services (HHS) just in Part B pay the monthly premium. The compared to $105 in 2003. announced the Medicare pre- Part A deductible applies only to those Most Medicare beneficiaries do not mium, deductible and coinsur- enrolled in the original fee-for-service pay a premium for Part A services since Tance amounts to be paid by Medicare Medicare program. Those who enroll in they have 40 quarters of Medicare- beneficiaries in 2004. private Medicare+Choice plans may not covered employment. However, seniors For Medicare Part A, which pays for be affected by the Part A increase, and and certain persons under age 65 with inpatient hospital, skilled nursing facil- may receive additional benefits with disabilities who have fewer than 30 ity, and some home health care, the de- different cost-sharing arrangements. quarters of coverage may obtain Part A ductible paid by the beneficiary will be About 95 percent of Medicare's 41.7 coverage by paying a monthly premium $876 in 2004, an increase of $36 from million beneficiaries are enrolled in the set according to a formula in the Medi- this year's $840 deductible. The monthly optional Part B, which helps pay for care statute at $343 for 2004, an increase premium paid by beneficiaries enrolled physician services, hospital outpatient of $27 from 2003. In addition, seniors in Medicare Part B, which covers physi- care, durable medical equipment and with 30 to 39 quarters of coverage, and cian services, outpatient hospital ser- other services, including some home certain disabled persons with 30 or more vices, certain home health services, dura- health care. Nearly 90 percent also have quarters of coverage, are entitled to pay ble medical equipment and other items, Tommy G. Thompson some form of supplemental coverage a reduced premium of $189. will be $66.60, an increase of 13.5 per- (such as Medigap, Medicaid, or Medi- States have programs that pay some cent or $7.90 over the $58.70 premium care+Choice) to help reduce out-of- or all of beneficiaries' premiums and for 2003. computing the Part A inpatient hospital pocket medical costs. coinsurance for certain people who have Medicare deductibles and premiums deductible. The Part A deductible is the benefici- Medicare and a low income. Information are updated annually in accordance with "These premium changes underscore ary's only cost for up to 60 days of Medi- is available at 1-800-MEDICARE (800- formulas set by law. The Part B pre- the need to improve and modernize the care-covered inpatient hospital care. 633-4227) and, for hearing and speech mium is required to be the amount Medicare program," HHS Secretary However, for extended Medicare- impaired, at TTY/TDD: 877-486-2048. needed to cover 25 percent of estimated Tommy G. Thompson said. "We need a covered hospital stays, beneficiaries program costs for enrollees aged 65 and Medicare system that provides more must pay an additional $219 per day for Information concerning the Social older. General revenue tax dollars cover choices for beneficiaries and more incen- days 61 through 90 in 2004, and $438 Security Cost of Living increase for 2004 the other 75 percent of the costs. The tives for efficient, high-quality care. per day for hospital stays beyond the was also released today and can be same statute prescribes the method for Choice and efficient care can help keep 90th day in a benefit period. For 2003, found at www.ssa.gov.

Parity Legislation Still Awaits As We Remember Senator Paul Wellstone

NAMI the year since his passing, a bipartisan tion: Chairman John Boehner (R-OH) of ● untreated mental illness costs Ameri- Washington, DC coalition of Senators and House mem- Education and the Workforce, W.J. can businesses, government and families bers has continued the cause for which (Billy) Tauzin (R-LA) of Energy and at least $79 billion annually in lost pro- ctober 25 marked the 1st an- he worked for passionately – legislation Commerce and Bill Thomas (R-CA) of ductivity and unemployment, broken niversary of the passing of an to require health plans to cover treatment Ways and Means. lives and broken families, emergency unrivaled champion for peo- for mental illness on the same terms and All Senators and House members can room visits, homelessness and unneces- O ple living with severe mental conditions as all other illnesses – insur- be reached through the toll-free Parity sary use of jails and prisons, illness and their families – Senator Paul ance parity. This legislation remains Hotline, 1-866-PARITY4 (1-866-727- Wellstone. In memory of his legacy and stalled in Congress, despite support from 4894). The Parity Hotline reaches the ● mental illnesses such as schizophre- in celebration of his life, NAMI advo- 66 Senators, 243 House members and Capitol Switchboard, which can connect nia, bipolar disorder, major depression, cates are urged to call their members of President Bush. callers to their members of Congress. obsessive-compulsive disorder and se- Congress this week and urge immediate Advocates are urged to call their When calling members of Congress, vere anxiety disorders are real illnesses, action on mental illness insurance parity members of Congress and urge them to remind them that: legislation (S 486/HR 953 – the Paul move the Paul Wellstone Mental Health Wellstone Mental Health Equitable Equitable Treatment Act of 2003 for- ● President Bush supports efforts in ● treatment for mental illness works, if Treatment Act of 2003). ward immediately and pass it before Congress to pass a federal parity bill and you can get it – treatment efficacy rates Paul Wellstone’s life and service in Congress adjourns for the year. Senators on April 29, 2002 declared "Senator for most severe mental illnesses exceed the United States Senate was grounded should especially be urged to contact Domenici and I share this commitment: those for heart disease and diabetes, in his personal experience as a family Majority Leader Bill Frist (R-TN) and health plans should not be allowed to member of a brother living with schizo- Senate HELP Committee Chairman Judd apply unfair treatment limitations or ● there is simply no scientific or medi- phrenia and his unending quest to end Gregg (R-NH). Likewise, House mem- financial requirements on mental health cal justification for insurance coverage discrimination against children and bers should be urged to contact Speaker benefits. It is critical that we provide full of mental illness treatment to be on dif- adults living with mental illness. While Dennis Hastert (R-IL) and the Chairmen mental health parity and that we do not ferent terms and conditions than other his work was not finished before his of the three House Committees that con- significantly run up the cost of health diseases, death, his legacy of activism lives on. In tinue to delay action on parity legisla- care," see Parity on page 55 MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 9

MENTAL HEALTH NEWSDESK

Mutant Serotonin Transporter Gene Is Linked To Obsessive Compulsive Disorder

National Institute of Mental Health The scientists analyzed DNA from Washington, DC 170 unrelated individuals, including 30 patients each with OCD, eating disor- ders, and seasonal affective disorder, nalysis of DNA samples from plus 80 healthy control subjects. They patients with obsessive com- detected gene variants by scanning the pulsive disorder (OCD) and hSERT gene’s coding sequence. A sub- A related illnesses suggests that stitution of Val425 for Ile425 in the se- these neuropsychiatric disorders affect- quence occurred in two patients with ing mood and behavior are associated OCD and their families, but not in addi- with an uncommon mutant, malfunction- tional patients or controls. Although ing gene that leads to faulty transporter rare, with the I425V mutation found in function and regulation. Norio Ozaki, two unrelated families, the researchers M.D., Ph.D., and colleagues in the col- propose it is likely to exist in other fami- laborative study explain their findings in lies with OCD and related disorders. the October 23 Molecular Psychiatry. In addition to the I425V mutation, the Researchers funded by the National two original subjects and their two sib- Institutes of Health have found a muta- lings had a particular form of another tion in the human serotonin transporter hSERT variant, two long alleles of the 5- gene, hSERT, in unrelated families with HTTLPR polymorphism. This variant, OCD. A second variant in the same gene associated with increased expression and of some patients with this mutation sug- function of the serotonin transporter, gests a genetic “double hit,” resulting in suggests a “double hit,” or two changes greater biochemical effects and more gene in a way that appears associated viduals with the mutation had OCD or within the same gene. The combination severe symptoms. Among the 10 leading with symptoms of a disorder,” said co- OC personality disorder and some also of these changes, both of which increase causes of disability worldwide, OCD is a author Dennis Murphy, M.D., National had anorexia nervosa (AN), Asperger’s serotonin transport by themselves, may mental illness characterized by repetitive Institute of Mental Health Laboratory of syndrome (AS), social phobia, tic disor- explain the unusual severity and treat- unwanted thoughts and behaviors that Clinical Science. “This step forward der, and alcohol or other substance ment resistance of the illnesses in the impair daily life. gives us a glimpse of the complications abuse/dependence. Researchers found subjects and their siblings. “In all of molecular medicine, there ahead in studying the genetic complexity an unusual cluster of OCD, AN, and “This is a new model for neuropsy- are few known instances where two vari- of neuropsychiatric disorders.” AS/autism, disorders together with the chiatric genetics, the concept of two or ants within one gene have been found to Psychiatric interviews of the patients’ mutation in approximately one percent maybe more alter the expression and regulation of the families revealed that 6 of the 7 indi- of individuals with OCD. see Gene on page 55

Research Shows Cigarette Smoking Reduces Levels of MAO in Organs Outside of Lungs

Dept. of Health and Human Services "When we think about smoking and Washington, DC the harmful effects of smoke, we usually think of the lungs and of nicotine," says NIDA Director Dr. Nora D. Volkow, one t is well known that smoking ciga- of the authors of the study. "But here rettes can directly and often fatally we see a marked effect on a major body damage the lungs. But new re- enzyme in sites far removed from the search, with support from the Na- lungs that we know is due to a substance Itional Institute for Biomedical Imaging other than nicotine. This alerts us to the and Bioengineering and the National fact that smoking, which is highly addic- Institute on Drug Abuse, National Insti- tive, exposes the whole body to the thou- tutes of Health, and the Department of sands of compounds in tobacco smoke." Energy, shows that cigarette smoke also Dr. Joanna Fowler, together with decreases levels of a critical enzyme Dr. Volkow and others at Brookhaven called monoamine oxidase B (MAO B) National Laboratory and the State Uni- in the kidneys, heart, lungs, and spleen. versity of New York at Stony Brook, Too much or too little of this crucial conducted the study, which will be pub- enzyme can have an effect on a person's lished online during the week of Septem- mental or physical health. ber 8 on the Proceedings of the National MAO B is important because it radioactive compounds to produce im- States alone," says NIH Director Dr. Academy of Sciences Web site. breaks down the chemicals that allow ages of biochemical processes within Elias Zerhouni. "This new finding high- Dr. Fowler and the research team nerve cells to communicate and regulate living systems. lights the fact that the act of smoking compared PET scans showing MAO B blood pressure. "Smoking is a major public health cigarettes can affect biochemical sys- activity in 12 smokers with scans from 8 PET, or positron emission tomogra- problem that results in approximately tems within multiple organs other than nonsmokers. phy, employs computer technology and 440,000 deaths per year in the United the lungs and upper airways." see Smoking on page 55 PAGE 10 MENTAL HEALTH NEWS ~ WINTER 2004

MENTAL HEALTH NEWSDESK

Supported Employment in the Hudson River Region

By Jack Smitka, Vocational Liaison the only PBC project in NYS with this NYS-OMH Hudson River Field unique collaborative peer support rela- tionship. Gateway’s PBC project, with the sup- t was difficult for Mary to even port of PEOPLe, worked with Mary to imagine a functional life outside of establish her in a Section 8 apartment. her world of anxiety and clinical Mary calls it taking little steps, but with depression. Her struggle with men- her housing situation stabilized she felt Ital illness has led her to access an array that she was ready to move on with her of inpatient and outpatient mental health life. With the strong support of the mile- services. Years of physical and mental stone manager, Sandy, Mary has been abuse had her convinced that, at middle employed, as a hostess at a local Pizza age, she was virtually worthless. It is a Hut, for 16 months now. She receives story that may be familiar to you. Mary follow along services, such as benefits was living day to day with her percep- The peers at PEOPLe work individu- State to participate in a NYS Office of counseling, on two occasions every tion of reality until she met a representa- ally and in group sessions to explore an Mental Health (OMH) funded demon- month. Her intellect and personality are tive of PEOPLe, Inc. PEOPLe is a peer individual’s vocational needs and desire stration project called Performance starting to reemerge. She is now inter- support and advocacy program in Pough- to work. They identify personal values Based Contracting (PBC). PBC, also ested in continuing her education to ex- keepsie, NY. PEOPLe, in a cooperative and potential barriers to employment. know as the milestone project, is a fund- pand her employment options. She even relationship with the Dutchess County Life skills assessments, which include an ing initiative designed to stimulate fo- saved up enough money to take a cruise Continuing Day Treatment Center, inventory of work interests, experiences cused supported employment (SE) im- recently. reaches out to individuals, like Mary, to and skills, are completed in coordination plementation. Demonstration project Mary’s life has changed dramatically promote the value of work. Fear and with Gateway Community Services. contractors are provided financial incen- because of this effective collaborative self-doubt are their opponents, but an “if Gateway is based in Kingston, NY and tives for successfully completing per- effort of mental health services. The I can do it, you can do it too” attitude is was selected as one of seven original formance outcomes or milestones. The Office of Mental Health the strength of their game. mental health providers in New York Dutchess County/Gateway initiative is see Hudson on page 50

Columbia University Researchers Present At Hudson Valley MHA Suicide Symposium

By Ann Marie Maglione episode of major depression were receiv- Director for Community Relations ing at least a minimal therapeutic dose of MHA in Orange County medication”. These studies will be dis- cussed in further detail when MHA, in collaboration with the Orange County ental Health Association in Department of Mental Health and Or- Orange County, Inc. ange Regional Medical Center, Arden (MHA) is on the cutting Hill campus will host the Annual Jeanne edge in providing accessi- Jonas Professional Development Sympo- Mble mental health services as well as sium. The topic will be titled “ Suicide educating the public regarding mental Prevention, working with recipients who health issues. The foundation for our have a history of suicide attempts and services is an evidence-based approach persons at risk for suicide “. to recognizable problems. Please visit our website for more in- Throughout the year, MHA in Orange formation regarding the Jeanne Jonas County offers a variety of educational Symposium and a variety of other programs and support groups on mental events. health issues for professionals and the MHA seeks to promote the mental public including conferences, seminars, health and emotional well being of Or- training for family members and mental ange County residents, working toward health screening programs. reducing the stigma of mental illness, A major focus of MHA is to link indi- developmental disabilities, and provid- viduals at-risk to the appropriate services ing support to victims of sexual assault to prevent adverse outcomes such as Community education is MHA’s On November 18, MHA in Orange and other crimes through 23 programs family disruption, job loss and suicide. forte. We continue to strive in order to County co-sponsored a presentation on and several support groups. On line depression screening is available make mental health issues a priority in suicide prevention by researchers from MHA shares the belief that every on the MHA in Orange County’s website schools. We integrate the schools with the Department of Psychiatry at Colum- person has dignity and is to be treated www.mhaorangeny.com throughout the MHA by offering a variety of confer- bia University. Among the finding of with respect, compassion and accep- year. This confidential screening is ences, seminars and outreaches. Some of researchers at Columbia are: “Treatment tance. available to all and is the first step in the topics discussed are, sexual assault, of psychiatric illnesses will reduce sui- receiving treatment and in many cases, date rape, eating disorders and peer pres- cide rates. Psychological observations in The MHA in Orange County is lo- preventing suicide. In addition, a 24- sure. Each of these separately, if allowed completed suicides confirm that over cated at 20 Walker Street, in Goshen, hour information and referral to fester without intervention could po- 90% have a diagnosable psychiatric ill- New York. You may contact their office HELPLINE 800.832.1200 is available. tentially lead to suicidal thoughts. ness and only 12% of suicides during an at (845) 294-7411. MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 11

for this special suicide issue mental health news takes pride in honoring the American Association of Suicidology

for its dedication to the understanding and prevention of suicide

Suicide in America: equivalent of a declared war to fund the into conflict with authority such as the necessary research and prevention pro- police, get them suspended and expelled What We Know, and the grams at a level commensurate with our from school, etc.) are also common. Challenges that Lie Ahead stance on AIDS, Alzheimer’s disease, Anxiety disorders, particularly those etc. involving agitation and severe anxiety, By Alan L. Berman, Ph.D. Spurred by survivor-advocates, nota- when occurring concurrently with de- Executive Director, bly Jerry and Elsie Weyrauch, Georgians pression, appear to increase risk. In fact, American Association of Suicidology who lost their physician-daughter to sui- “co-morbidity,” the co-occurrence of cide, and Senator Harry Reid (D-NV) two or more of a variety of diagnostic who lost his father to suicide, congres- conditions, heightens risk for suicide uicide happens! In 2001 (the sional resolutions were passed declaring considerably. Thus, schizophrenia is latest year for which we have suicide a focus of major national concern more of a risk factor when there is a co- national statistics), 30,622 and a federally-sponsored conference morbid depressive episode, depression Americans completed suicide-- was organized and held in Reno, Nevada and substance abuse form a more lethal S to initiate recommendations for suicide recipe for the potential for suicide, etc. one every seventeen minutes; eighty per day. What surprises most people to prevention. In 1999, then-Surgeon Gen- Why do mental disorders increase learn is that 75% more Americans die by eral Satcher published a Call to Action to vulnerability to suicide? First, they im- suicide each year than die by homicide. Prevent Suicide, followed two years later pair an individual’s resilience. Second, What may surprise most people to know with his far-reaching National Strategy they amplify feelings of distress. Lastly, is that the great majority of these tragic to Prevent Suicide (NSSP). The NSSP they impair coping abilities to deal with - systematically laid out 11 goals and 68 - and decrease protections from -- stress- and premature deaths are preventable. Alan L. Berman, Ph.D. Suicide is our 11th leading cause of objectives that federal and private sector ful conditions. Mental disorders are death. Among the young, however, it experts believed would significantly associated with greater likelihood of ranks third. It is four times more fre- save lives. In just the past two years the make one prone to being socially un- impulsive behavior, lessened ability to quent among men than women; twice as prestigious Institute of Medicine re- skilled, isolated, and lonely at an early think rationally and problem-solve effec- frequent among whites than blacks; and leased a significant scientific report, age. Current risk factors of significance tively, greater interpersonal conflict and particularly more common among the aptly titled Reducing Suicide: A National include having one or more mental dis- loss, reduced confidence in effectively elderly. But there is no category of peo- Imperative; and just this year the Presi- orders, substance abuse, feelings of dealing with stress, thus greater avoid- ple that is immune to the possibility that dent’s New Freedom Commission made hopelessness or burdensomeness, having ance, etc. loved ones will carry a lifetime label of suicide prevention the first of its several poor impulse control and a low frustra- A number of mental disorders are recommendations to combat the nation’s suicide survivor. tion tolerance, rage and aggression. In also linked through neurobiological mental health crisis. Moreover, for every completed sui- this regard, it is interesting to note that pathways. Low levels of serotonin me- With suicide prevention now on the cide in the U. S. there are 5 people hos- one Swedish study documented that both tabolites, for example, have been associ- pitalized each year for a nonfatal attempt nation’s radar screen, leaders in the field adolescents who are bullied and those are convinced that collaboration among ated with higher rates of future suicidal and an estimated 22 emergency depart- who were the bullies had higher rates of behavior, more lethal suicidal behavior, ment visits for less lethal self-harm be- multiple sectors of our society is essen- depression and suicidal ideation. Con- tial to effectively accomplish these and other forms of violence, e.g., arson. haviors – totaling almost 700,000 hospi- tributing to risk are having access to a Genetic factors have been linked to men- tal admissions annually for nonfatal sui- goals. Suicide must be understood as firearm -- used in almost 60% of all sui- multi-determined, having correlates that tal illnesses and to impulsive aggression, cidal behaviors. Whereas completed cides, being exposed to suicide by oth- liabilities which when taken together suicides are much more frequent among range from those biological to psycho- ers, and having negative thoughts about logical, social and cultural, political and increase suicidal risk. Suicides do ap- males, nonfatal attempts are made by one’s self, such as being unworthy, pear to aggregate in some families. females three times as often as by males, economic. Thus, suicide prevention will unlovable, and un-helpable. require collaborative partnerships among Twin studies have found a higher con- and the great majority of these are Psychological autopsy studies -- in- cordance for suicide among monozy- among our young. mental health and public health special- tensive retrospective analyses of the gotic (identical), versus dizygotic Since 1991, the Centers for Disease ists, those in criminal justice and faith- lives and deaths of people who have (fraternal), twins. Suicides, also, appear Control and Prevention (CDC) biannu- based communities, media professionals completed suicide -- have documented more frequently among biological rela- ally has surveyed an average of about and legislators, etc. rather convincingly that diagnosable tives of adoptees who had completed 15,000 high school students regarding In a public health approach, the steps mental disorders are present in approxi- their self-reported risk behaviors. Their toward preventing suicide begin with mately 90% of all suicides. Most com- suicide than among adoptive relatives. findings are disquieting. In their 2001 collecting data and establishing a clear mon among these are affective disorders It must be borne in mind that while survey, almost one in 5 students reported understanding of the problem. To that (depression), found in about 60% of all mental disorders create vulnerability to seriously considering suicide in the past extent it is important that we understand suicides. According to the National In- suicide, the great majority of those with 12 months, one in seven said they had what we know and what we yet need to stitute for Mental Health, severe depres- mental disorders do not suicide. Where made a plan, and one in 12 reported hav- learn. sion, i.e., that which includes suicide depression has been significantly related ing made a nonfatal attempt, for which ideation or attempt behavior that has to suicide, hopelessness is an even one third of these youth had to seek Risk Factors for Suicide required hospitalization, carries a life- stronger correlate. Hopelessness is un- medical attention. In a typical American and Suicidal Behaviors time risk of suicide in the range of 6%. derstood as a constellation of negative high school classroom, two females and That being said, depression is neither a thoughts about self (“I’m unlovable”), one male will make a suicide attempt Understanding suicide requires us to necessary, nor a sufficient condition to about others (“Nobody cares about me”), this year. first understand what makes an individ- understand suicide. Keep in mind that an and the future (“Nothing will ever Before age 65, a total of more than ual vulnerable to being suicidal. Suici- estimated 40% of those who die by sui- change”). Despair and what psycholo- 500,000 years of potential life are lost as dologists (those who study suicide) term cide are not depressed. In adolescence, gist Edwin Shneidman called a result of suicides in our nation. The these characteristics of vulnerability it has been estimated that the ratio of “psychache”, an intolerable state of per- economic burden of suicide is mind- “predisposing risk factors”. Predispos- depressed to depressed suicidal adoles- turbation, push individuals toward want- ing risk factors are both historical and boggling, estimated at almost 12 billion cents is more than 600:1. ing to escape their pain. current for any individual. Those that dollars annually in the U.S. (Goldsmith Among adults, alcoholism (in ap- Once an individual makes a nonfatal are historical in anyone’s life include, for et al, 2002). proximately 25%) and schizophrenia (in suicide attempt, the likelihood of a sec- example, having a family history of sui- Beginning in 1996, the United States approximately 10%) are next most fre- ond attempt and/or a suicide completion has initiated several steps toward estab- cide, violence, or significant mental dis- quently associated with suicide. Among order; early histories of childhood abuse increases. About a third of all nonfatal lishing a preventive mentality toward younger people, substance abuse (drugs attempts are followed by more suicidal suicide, including labeling suicide a ma- (physical, sexual, and/or emotional); and/or alcohol) and conduct disorders and/or developmental skill deficits that behavior, jor public health problem requiring the (disorders of behavior that bring youth see AAS on page 14 PAGE 12 MENTAL HEALTH NEWS ~ WINTER 2004 Predicting Suicide: A Dilemma Faced By The Treating Physician

By L. Mark Russakoff, M.D. attempted suicide. The determi- are overridden by suicidal urges, take extra note of the state vari- Director of Psychiatry nants of suicide and suicide at- the survivors often feel guilty or ables. Phelps Memorial Hospital Center tempts differ. betrayed. Certain situations are One of the most obvious state One of the critical tasks of men- more likely to precipitate suicide in variables is the expression – in tal health providers is to assess in- a vulnerable individual. various degrees – of the wish to dividuals for suicidal risk and to The parameters of assessment die. For persons who either articu- estimate the immediacy of that risk. include aspects that are cultural and late intent to kill themselves or who The determination that a person is biopsychosocial, which are then have made an attempt, there are at imminent risk for suicide leads impacted by economic factors that various parameters that are consid- to one of the few circumstances in involve healthcare reimbursement. ered. The degree of intent to kill which the rules of confidentiality Clinical factors that impact risk oneself is assessed through ques- are relaxed and coercive interven- assessment may be divided into tioning about the articulation of tion may occur. If a psychiatrist trait and state factors. Trait factors that intent. A person who has just believes that a person is at immi- are those which do not change, are acted on their intent is presumed to nent risk for suicide, and that inten- enduring. A trait factor has limited have a greater intent than one who tion is a product of a mental illness, utility in clinical suicide prediction is contemplating a similar action. then the psychiatrist is ethically since once it is true – the person is It is believed that a person who has obliged to act to prevent such an male, has a history of depression – fleeting thoughts of “it’s hard to go act. This action might include it is true forever and places the per- on” has less intent than someone alerting a family member or signifi- son at higher, chronic risk. State thinking “life is not worth living,” cant other to the risk. It might also factors are not fixed, but transient who has less intent than someone include calling 911 for an ambu- or at least subject to change. who plans “I will go and overdose lance and assistance in getting a Demographic factors strongly asso- on my sleeping pills.” The dimen- patient to a hospital. Similarly, one ciated with suicide include male sions of the articulation of intent L. Mark Russakoff, M.D. of the criteria for admitting a per- sex, older age, race, religion - but include whether the idea is fleeting son to the hospital against their will are of limited utility in that they are or impulsive or enduring and shows is if they are deemed to be at immi- immutable factors, best for epide- planning. Additionally, whether the nent risk for committing suicide. miological studies. plan is contingent is thought to af- uicide is one of the most Kendra’s Law, the Assisted Outpa- Social factors, including fect risk, e.g. if my wife leaves me vexing problems that con- tient Treatment legislation, permits whether the person is married, re- I’ll kill myself. Intent expressed in front mental health provid- the obtaining of court orders to en- cently lost a relationship, recently the context of severe depression S ers, patients and their fami- force outpatient treatment for per- unemployed, of higher social stand- would be considered as higher risk lies. Its occurrence is relatively sons who have repeatedly at- ing in the community, also contrib- than intent in someone not de- rare: the suicide rate in the United tempted to hurt themselves. ute to the long-term risk of suicide. pressed (absent other unique fea- States remains about 11-12 persons However, the assessment of sui- Psychological factors include feel- tures, such as a person threatening in 100,000. The likely determi- cidal risk and the prediction of sui- ings of depression, anxiety – par- suicide if sent to jail). nants of suicidal behaviors are mul- cide are fraught with problems. ticularly panic anxiety, helpless- The availability and type of the tiple and interacting. The combina- There are no characteristics that ness, hopelessness and personality intended means also affects risk tion of the rarity of the event and clearly distinguish those who go on style. Diagnosis is a factor, with assessment. The intention of using its multiple, interacting contribut- to commit suicide from those who conditions such as major depres- a gun that one owns is presumed to ing factors makes the prediction of do not. All the tools that have been sion, alcohol dependence, schizo- represent a higher level of intent suicide extraordinarily difficult. developed to predict subsequent phrenia and borderline personality and risk than the plan to go to an- Suicide attempts are much more suicidal acts grossly over-predict disorder all associated with in- other part of the country, purchase frequent. the number of people who will do creased risk. Biological factors a weapon, etc. The plan to use a It wasn’t until 1952 that the dis- so (that is, identify many more peo- have been shown to relate to sui- means that is available and irre- tinction between suicide and at- ple as suicidal than who truly are) cide – low serotonin levels in the versible is seen as representing a tempted suicide was clearly drawn. while at the same time under- spinal fluid. Family studies sug- higher risk than one that is less Until that time, attempted suicide predict a large portion (that is, miss gest a potential genetic basis in available and reversible, e.g. shoot- was seen as a bungled suicide. It many people who do go on to sui- some cases. ing oneself with a gun one owns was noted at that time that the epi- cide). Notwithstanding those prob- For the clinician, this means that versus overdosing on pills. One of demiological characteristics of lems, clinicians are obliged to per- an older, divorced white man, with the interventions that may be made those who committed suicide were form such assessments and to act a history of major depression and with someone who acknowledges dramatically different than those accordingly. We will return to this alcoholism who presents in the suicidal thoughts is to remove ac- who attempted suicide: people who dilemma later. doctor’s office is already a high cess to the means of suicide, e.g. committed suicide were typically A number of factors place peo- risk for suicide. Although this per- surrender a gun, have a significant older white males and people who ple at persistent higher risk, others son is at high risk to eventually other hold one’s medications, etc. attempted suicides were typically may be protective, and some fac- commit suicide (from an epidemi- Sometimes the inclusion of the sig- younger females. The recognition tors may be related primarily to ological perspective) the actual nificant other in the process helps that there were two distinct but acute risk. Some factors may be likelihood that he will kill himself beyond the fact of the removal of overlapping populations at risk led protective against suicidal acts. in the near future – no other infor- means in that it facilitates commu- to an exploration of the social con- Strong religious beliefs may ex- mation being available – is quite nication between the two people text and meanings of suicidal be- clude suicide as an option to a per- low. However, knowing that cer- regarding the seriousness of the haviors. It was noted that a signifi- son. Strong, close connections to tain characteristics places an indi- situation. cant proportion of people who family may also mitigate suicidal vidual at higher risk for subsequent committed suicide had previously intent, but when these protections suicide, does alert the clinician to see Dilemma on next page MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 13

Dilemma from previous page assessment of suicidal risk. Ques- that implies there is no point in tell- left to professionals. There are in- tions are raised by managed care ing others; it is not a matter of “I dividuals who frequently hurt Healthcare reimbursement prac- reviewers about the veracity of cannot do it but someone else can” themselves without the intention or tices have clouded the picture of statements that a person feels suici- it is a matter of “no one can help likely risk of dying. These behav- suicide assessment and prediction. dal, putting clinicians in the posi- me.” If the feeling is “no one can iors have been designated as Managed care in psychiatry has tion of being arbiters of the truth as help me,” then there is no point in “parasuicidal” and require separate assumed that inpatient care has opposed to healers. Alternatively, sharing one’s intentions with oth- discussion. been over utilized. Thus the criteria clinicians must “see” acute suicidal ers. This discussion of helpless- The dilemma for clinicians is for admission to a psychiatric inpa- risk in an individual in order to jus- ness and hopelessness is drawn as that they are mandated to be on the tient facility has typically collapsed tify the admission (that both the if there is a sharp distinction, with alert for suicidal behaviors, have into criteria for imminent danger- patient and the clinician feel is ap- either feeling state very sharply broad clues to suicidal risk but little ousness. Whereas in the past ad- propriate) to the managed care re- defined. Like most things in life, ability to accurately predict it. If mission to the hospital might be for viewers. these states are not so black or suicidal risk is deemed to be immi- support and relief of psychic pain, One of the first publications white, but appear in shades of gray. nent, then the clinician’s hands are including respite from intolerable from the Suicide Prevention Center Otherwise hopeless feeling indi- forced to act to prevent such an circumstances, now the criterion in Los Angeles was titled The Cry viduals often share their feelings outcome. A clinician too sensitive that typically determines whether for Help. In fact, far more people with others and provide an opportu- to suicidal risk will pressure many the managed care company will talk about suicide than attempt or nity to intervene. people into higher levels of care pay for the admission is that the commit suicide. It is quite com- If a person articulates specific than is warranted. A clinician who person is in such distress that sui- mon for people who subsequently thoughts of intention and means, is insensitive will miss the clues at cide or other dangerous behavior is attempt or actually commit suicide then evaluation by a mental health grievous cost. Because of the in- likely if the person is not hospital- to talk about their feelings and con- professional is indicated. Since ability to accurately predict such ized. The criterion for admission cerns before they act. Significant helplessness and hopelessness are behaviors, the best clinician, if he has moved from that of “medically others and family members need to common in suicidal individuals, or she treats enough patients, is necessary” to that of “medically acknowledge such communications assisting the person to obtain such likely to fail to anticipate a suicide. essential.” Persons sometimes pre- and at least offer to explore the per- an evaluation is not enabling but Clinicians who treat populations at sent to the emergency rooms feel- son’s concerns. Feelings of help- potentially life-saving. There are high risk are more likely to have ing very distressed and realize that lessness often underlie suicide at- anecdotes about “crying wolf” – such outcomes than clinicians who they need to assert that they are tempts. More often, simple ac- but would one rather have re- shy away from such work. Clini- acutely suicidal in order to have the knowledgement that the person sponded to the cry or regret one’s cians strive to develop relationships admission approved. feels so badly is sufficient to allevi- disregard of the cry? This is not to with their patients so that they Clinicians are not mind readers, ate that sense. Unfortunately, feel- say that there is no room for profes- work collaboratively towards the and subjective report – what the ings of hopelessness often underlie sional judgments in such assess- goal of recovery without the occur- patient says - is typically central to suicides. Hopelessness is a feeling ments, but such decisions are best rence of self-destructive acts. PAGE 14 MENTAL HEALTH NEWS ~ WINTER 2004

AAS from page 11 ability and accessibility of a firearm is Risk Factors for Adolescent Kingdom limiting the number of pills also a risk factor for suicide. In the U. S. Suicide: A sampling per packet and the number of packets the majority of these within twelve firearms are the most common method one could purchase led to a dramatic and months of the first attempt. The lifetime of suicide for the young and the old, for • Depression, both unipolar immediate decline in paracetamol (their risk of completing suicide for those who males and for females, for whites, and bipolar version of acetaminophen) overdose have made a nonfatal attempt is between blacks, and Native Americans. The • Drug and alcohol abuse deaths. Bridge barriers on the Ellington 10 and 15%. Some believe that a prior CDC has noted that the suicide rate of Bridge in Washington, DC reduced the attempt serves as a sort of dress re- children under 15 years of age in the U. • Conduct disorder annual number of jumps from almost 4 hearsal, decreasing some of the inhibi- S. is twice as high as it is in 25 other • Co-morbid disorder to 0, with no appreciable increase on the tory anxiety and self-preservation in- industrial countries combined; virtually immediately neighboring Taft Bridge. • Borderline personality disorder stinct that sustains most individuals. all the difference is attributable to fire- • Suicidal ideation States with strict gun control laws have Attachments to others for social sup- arms. The risk of suicide of a household lower suicide rates; states with laws re- port are protective factors, decreasing member is increased nearly five times • Suicidal communications, quiring safe storage of firearms have the likelihood of suicidal behavior. Di- when there is a gun kept in the home verbal, written, etc. lower rates of firearm suicides. vorce (for men, in particular) and separa- versus when there is not. In the majority • Hopelessness Early detection, referral and treatment tion (acute losses) lead to higher rates of of homes where there is both at least one • Impulsivity models are effective in detecting and suicide; being married and having chil- gun and a child, the gun is kept helping those at risk. Hotlines and crisis • Intense rage; aggressive and dren (for women, in particular) are asso- unlocked, thus accessible for immediate violent behaviors centers serve as gatekeepers for those in ciated with lower rates of suicide. Fam- use to suicide. crisis and can effect referrals to commu- ily discord and social isolation are asso- While we have learned a fair amount • Social isolation: Withdrawn, nity caregivers. School screening pro- ciated with higher rates of suicidal be- about risk factors for suicide, we know isolated, alienated, lonely grams, similarly, are able to identify and havior; family cohesion has consistently far less about warning signs for suicide. • Family history of suicide refer those at risk at the time of screen- been found to be protective. Attach- Suicides are not readily predictable, even • Parental history of major psychiatric ing. In the most widely touted of these ments to belief systems, for example in the immediate near-term. One may be disorder or substance abuse models, the U. S. Air Force created a participation in religious activities suicidal at some level of potential to act service-wide suicide prevention program (religiosity) provide yet other social at- throughout one’s lifetime and never act. • Family instability and conflict designed to encourage detection and tachments as well and protect against On the other hand, about a third of • Problem-solving skill deficits treatment of at-risk personnel. The con- suicide. nearly fatal suicidal acts appear to have sequence of their efforts was a 55% de- • Exposure to others suicidal behavior Socio-cultural conditions are impor- occurred, according to surviving victims, • Heightened stress as triggers cline in suicide rates. tant to understand as they influence sui- totally on impulse, i.e., within five min- The National Strategy for Suicide cidal behaviors. Unemployment and utes of the thought or impulse reaching • Access to means: Firearm Prevention outlines 11 goals that com- economic distress are significantly re- consciousness. Clearly, individuals un- availability and accessibility prehensively organize what can and will lated to suicidal behaviors. Social der conditions of stress and distress who make a difference in the lives of our citi- change, e.g., modernization and migra- talk of wanting to be dead or threaten to What is important to understand is zenry. In addition to educating the pub- tion, leads to higher rates of economic harm themselves must be taken seri- that most people at risk either communi- lic to understand what is known about difficulties for some and alcoholism for ously. Vulnerable individuals faced with cate their intent or are in position to be suicide and its preventability and build- others, leading, in turn, to higher rates of conditions of shame or humiliation may noticed, observed, and asked questions. ing public-private coalitions to provide suicide. not overtly communicate suicidality, but Approximately three of every four per- leadership and effective management for As impulsivity has been significantly surely need to be understood as being at sons who complete suicide have verbal- community and state-based prevention associated with suicide, the ready avail- increased risk for suicidal behavior. ized their intentions to one or another programs, the Strategy recommends: individuals before acting. The majority • Destigmatizing mental illness and of those suicidal have visited their pri- mary care physician within 30 days of substance abuse disorders to in- their deaths. Sixty percent (60%) of crease access to treatment by reduc- American Association of Suicidology schizophrenic patients were seen by a ing financial barriers, integrating care, and increasing willingness of clinician within 3 days of their suicides. THE FACTS ABOUT SUICIDE Where we have opportunity to intervene individuals, especially males, to seek treatment; by observing another’s behavior, asking about their emotional states, and even • Developing technical support to • Suicide is the ninth leading cause of death (2000 data) in directly asking whether they harbor sui- build capacity for states and institu- the U.S., claiming 29,350 lives per year. cidal thoughts, we have the opportunity tions, e.g., schools, prisons, youth service programs, to develop com- • Suicide rates among youth (ages 15-24) have increased to intervene and refer them for help. prehensive suicide prevention pro- more than 200% in the last fifty years. Early detection and referral are key concepts in preventing suicide. Training grams; • The suicide rate is highest for the elderly (ages 85+) than “gatekeepers” – teachers, physicians, • Limiting access to lethal means by for any other age group. parents, and others in position to observe educating health care providers and and act -- can save lives and is central to others to reduce their accessibility • Suicide is preventable. Most suicidal people desperately models of prevention. But first, we must and improving safety designs and want to live; they are just unable to see alternatives to truly understand and believe that suicide training; is preventable. And, we have to shed their problems. • Educating mental health providers stigmatic attitudes toward suicide so that and others (educators, attorneys, • Most suicidal people give definite warning signals of we may act to save lives. correctional workers) and family their suicidal intentions; but others are often unaware of Is suicide preventable? members to better identify and the significance of these warnings or unsure what to do Surgeon General Satcher stated un- (clinicians) to better treat at-risk about them. individuals; equivocably that suicide is a preventable public health problem. He was right. • Talking about suicide does not cause someone to become • Promoting and supporting the pres- We have at our disposal a variety of pre- ence of protective factors (problem- suicidal. vention models and examples of success- solving skills, non-violent conflict • Four times more men than women kill themselves; but ful programs. resolution skills, etc.); improving Means restriction models focus on primary care screening of risk, etc. three times more women than men attempt suicide. reducing access to available means of • Reducing structural barriers, e.g., • Firearms are the most common method of suicide among lethality or reducing the lethality of health insurance coverage, to receiv- available means to suicide, thus prevent- all groups (male, female, elderly, youth, black and white). ing adequate care; ing the impulsive suicide and giving opportunity for intervention. Domestic • Improving media portrayals of suici- • Suicide cuts across ethnic, economic, social and age dal behavior to decrease possibilities boundaries. gas poisoning once was the leading means of suicide in Great Britain. A of imitative behavior and increase proactive behaviors; • Surviving family members not only suffer the loss of a decrease in the carbon monoxide content loved one to suicide, but are also themselves at higher of available gas, thus its deadliness • Promoting research to evaluate sui- risk of suicide and emotional problems. (lethality), led to a 15 year decline in the cide prevention initiatives; and suicide rate in Great Britain after detoxi- fication. Recent legislation in the United see AAS on page 24 MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 15

If You Are Thinking About Suicide...Read This First

By Martha Ainsworth whether or not you really will end your From the Website: life. Often people feel that, even in the www.metanoia.org/suicide deepest darkness of despair. Being un- sure about dying is okay and normal. The fact that you are still alive at this

f you are feeling suicidal now, minute means you are still a little bit EWS please stop long enough to read unsure. It means that even while you this. It will only take about five want to die, at the same time some part minutes. I do not want to talk you of you still wants to live. So let’s hang Iout of your bad feelings. I am not a on to that, and keep going for a few therapist or other mental health profes- more minutes. Start by considering this sional - only someone who knows what statement:

it is like to be in pain. N I don’t know who you are, or why “Suicide is not chosen; it happens you are reading this page. I only know when pain exceeds that for the moment, you’re reading it, resources for coping with pain.” and that is good. I can assume that you are here because you are troubled and That’s all it’s about. You are not a considering ending your life. If it were bad person, or crazy, or weak, or flawed, possible, I would prefer to be there with because you feel suicidal. It doesn’t you at this moment, to sit with you and even mean that you really want to die - it Can Your talk, face to face and heart to heart. But only means that you have more pain since that is not possible, we will have to than you can cope with right now. If I make do with this. start piling weights on your shoulders, Community I have known a lot of people who you will eventually collapse if I add have wanted to kill themselves, so I enough weights... no matter how much have some small idea of what you might you want to remain standing. Willpower Afford be feeling. I know that you might not be has nothing to do with it. Of course you up to reading a long book, so I am going would cheer yourself up, if you could. to keep this short. While we are together Don’t accept it if someone tells you, To Not Have here for the next five minutes, I have “that’s not enough to be suicidal about.” five simple, practical things I would like There are many kinds of pain that may to share with you. I won’t argue with lead to suicide. Whether or not the pain An Assertive you about whether you should kill your- is bearable may differ from person to self. But I assume that if you are think- person. What might be bearable to ing about it, you feel pretty bad. someone else, may not be bearable to EALTH Mental Health Well, you’re still reading, and that’s you. The point at which the pain be- very good. I’d like to ask you to stay comes unbearable depends on what with me for the rest of this page. I hope kinds of coping resources you have. it means that you’re at least a tiny bit Individuals vary Education unsure, somewhere deep inside, about see Read This on page 58

H Program?

Let Us Help You Reach Out To Those Who Are At Risk ENTAL (914) 948-6699 M

PAGE 16 MENTAL HEALTH NEWS ~ WINTER 2004

Personal Journey from page 1 ing this man was one of 30,000 lives lost to suicide every year in the United States – But over the years he had slipped further that most people who die this way need help and further away from us into his ever deep- for untreated mental illness. They and their ening depression refusing all professional families don’t need scorn and judgment and help. A physician who dedicated his entire labeling – they are entitled to the same sen- scientific career to researching the human sitivity and unbiased coverage as the vic- brain, my father somehow could not deal tims of breast cancer and AIDS are afforded with the stigma associated with mental ill- by today’s news media. This was not just a ness and his own need for help. And every story about a cute dog surviving a tremen- year his depression would get worse in Feb- dous fall. Luckily my colleagues listened ruary during the dark winter months. But by and we produced some very in-depth televi- April or May he’d always pull out of it as sion news coverage that put the issue of the days grew longer and he could ride his suicide in the context where it belonged bike again to work – to his beloved lab at without unnecessary sensationalism. the nearby university. Unfortunately for some reason in the winter of 1983 he could ****** no longer function and simply didn’t know how to reach out for help. The incident with the man and his dog My parents were considered public fig- served as a catalyst for me to apply for a ures because of my father’s respected scien- journalism fellowship with former U.S. tific career and my mother served as one of First Lady Rosalynn Carter at The Carter the physicians to Urho Kekkonen, who was Center in Atlanta. Mrs. Carter had been an president of Finland from 1956 to 1981. advocate for mental health issues for dec- Former First Lady Mrs. Rosalynn Carter speaking at the Rosalynn Carter Therefore my father’s death generated some ades and each year she and her staff se- Symposium on Mental Health Policy at The Carter Center. Atlanta, media inquiries. I don’t remember much lected six journalists from across the nation about that morning but I do recall answer- for an opportunity to research and report on Nov. 8-9, 2000. Photo Credit: The Carter Center / Annemarie Poyo ing the phone and a reporter asking me to a mental health related subject of the re- confirm the way my father had died. And I porter’s own choosing. I was awarded the I made “Silent Screams” because I pression, Wallace grew concerned asking remember saying: “He died by suicide.” fellowship in 1999 and I ended up spending wanted to show that depression is a treat- me pointed questions about my treatment The news surrounding my father’s death the next two years putting together “Silent able illness. Had my father been able to and my medications. Calling me from his spread fast. And in the days, weeks and Screams.” When it was broadcast in Tampa reach out for help he’d still be here. “Silent vacation home in Martha’s Vineyard, Wal- months afterward I had to get used to a new in June 2001 it had the most viewers in its Screams” is dedicated to all those who felt lace spoke for several minutes and offered label. I became the girl whose father killed timeslot. I got hundreds of e-mails and like they couldn’t ask for help when they me his own personal advice. When we fi- himself. I got weird looks at school, I got letters thanking me for making the program. were depressed because the stigma associ- nally said goodbye an hour later I had a unsolicited comments from total strangers, The program was nominated for an Emmy ated with mental health issues stole their long list of things he wanted me to ask my and the minister at the church where I had Award later that fall and was included in the ability to speak out. The people interviewed doctors and he made me promise I’d let him attended for years told me my father was archives of the Museum of Broadcast Com- for “Silent Screams” all have one underly- know how it all turned out. going to hell. All of my father’s accom- munications in Chicago in 2002. ing message. “There is no shame in depres- Ultimately I was not surprised about plishments in life had suddenly been wiped “Silent Screams” is a compilation of six sion or any other mental health condition; Wallace’s support. He had alluded to his out and were now overshadowed by the separate segments covering depression, teen it’s OK to ask for help, and you can feel willingness to help others battling depres- morbid curiosity about his one last desper- suicide, suicide in the African American better.” sion in the original interview he had granted ate and irrational act. To many the way my community, the Yellow Ribbon suicide I know treatment works. I have a sister me about his own illness. And in my case father died seemed so much more important prevention program, as well as community who has battled clinical depression for his actions spoke even louder than his than the way he had lived. activism to reduce suicide deaths. Mrs. years, even being close to suicide several words. I muddled through high school and tried Carter also taped a public service announce- times. But unlike my father she was able to to ignore the label my family had been ment for the end of the program. In addi- reach out for help and has benefited from Interview with CBS News stuck with. And when it came time for me tion, I interviewed two well-known people successful treatment. I also know that from 60 Minutes correspondent Mike Wallace to go to college I made a clean break and about their personal struggles with depres- my own personal experience. In June 2000 excerpted from “Silent Screams” moved literally thousands of miles from the sion and suicidal thoughts. One was David only three weeks after interviewing Mike (taped May 2000) suburbs of Helsinki, Finland, settling in San Smith, whose ex-wife Susan Smith drowned Wallace I fell seriously ill with a digestive Francisco where nobody really knew my the couple’s two young sons in 1994 but disorder which left me bedridden for three family history. I finished my studies in three first claimed a carjacker had kidnapped her months. This experience also threw me into Wallace: I do it all the time. I do it all the years and got into journalism and thought and Michael, 3, and Alex, 14 months. In his a situational depression and for the first time. my painful experience with the stigma asso- extensive interview for "Silent Screams" time I could fully understand what my fa- ciated with suicide and mental illness was David told for the first time the entire story ther had gone through. Fortunately for me I Hyvarinen: How do you find time to do all behind me. of depression and suicide in his immediate could rely on my sister’s advice and her that? family and what role depression has played good experiences with her own treatment. I ****** in his life both before and after the death of also got help from a completely unexpected Wallace: I find time for this. I do. It does- his sons and how he learned to cope with source. n’t take much to help. If you can just get By 1998 my journalism career brought it. The other well-known person I inter- inside the head of the person who’s going me to Tampa, Fla., where I was working for viewed for “Silent Screams” was veteran ****** through it and persuade that individual it’s a CBS affiliate running its special projects journalist Mike Wallace of CBS News 60 curable. unit and doing longer in-depth pieces. I had Minutes. Wallace was one of the first public It was a Friday night in July 2000 and I been at that station for two years, won an figures in the U.S. who decided to be open was home alone recuperating from my ill- Hyvarinen: What does that mean to you? Emmy award for my work and fortunately I about his struggle with depression. His pub- ness. I had just taken my evening medica- had earned the respect of my co-workers. lic disclosure about his condition in an ac- tions and felt tired and lonely when the Wallace: It means a great deal. And you And there on a typical sunny Florida day claimed HBO documentary “Dead Blue” phone rang. It was about 7:30 pm in the hope with good reason that those individu- the stigma of suicide and mental illness had absolutely no negative impact on his evening and I wasn’t expecting any calls. I als whom you have helped find their way came rushing back to my life when a man successful and respected journalism career. grabbed the cordless phone next to the out of it and will do the same thing for other jumped to his death from a local bridge. Because of the generosity of the Carter sofa. The voice at the other end said: “Good folks. What made this man’s story different was Center Fellowship, I have been able to put evening, this is Mike Wallace and I hope I the fact that he held his dog while jumping. “Silent Screams” on the Internet at am not disturbing you.” Editor’s note: Liisa K. Hyvarinen is a The man died but his pet lived. In the ensu- www.silentscreams.tv . The program has Wallace was calling to check up on the freelance journalist based in Tampa, Fla., ing media frenzy over the dog’s recovery also become a popular suicide prevention progress I was making on the interview I working both in print and broadcast. She and who would get to adopt it from the education tool and I have literally shipped had taped with him. He had promised to also teaches journalism at University of pound, the man who died was largely for- out thousands of copies of it in the last two help me get some footage from CBS News South Florida, St Petersburg College and gotten. That bothered me and without a years. I still make VHS copies available for and was simply calling to see if I still Hillsborough Community College. Her most moment’s hesitation I shared with my news- educational purposes for $10. I’m currently needed that footage. When he could not find recent work has appeared in Marie Claire room colleagues for the first time my family working on a DVD version with the Gradu- me in my office it took the great investiga- magazine, The Denver Post, Chicago Trib- history of mental illness and the way my ate School of Journalism at Columbia Uni- tive reporter no time to find my unlisted une and Atlanta Journal Constitution. She father had died. versity in New York; the school uses home number. I disclosed my illness and recuperated from her situational depression At first the silence in the room was deaf- “Silent Screams” in its continuing education what had happened to me and that the doc- and was able to stop taking medications for ening. I pleaded for balanced coverage say- program. tors had diagnosed me with situational de- the illness in June 2002. MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 17 The NAMI-NYS Corner

Providing support to families and friends of individuals with mental illness and working to improve the quality of life for individuals with mental illness.

Helpline: 1 800-950-3228 (NY Only) - www.naminys.org - Families Helping Families

By J. David Seay, J.D. rassment to a state once proud of it pro- bills was introduced in the Senate this petitions and to contact their legislators Executive Director gressivism and compassion toward its year and it was passed. On its face, this in support of the Governor’s veto. NAMI-NYS most vulnerable citizens. But thanks to bill seems harmless enough, as it pur- In addition to the above-described the courage and commitment of Tom ports only to seek more data about ECT technical and public policy flaws of the and Donna O’Clair of Rotterdam, New and its use. However, a closer reading of legislation, NAMI’s position and ration- York, for whose late son Timothy’s Law the bill reveals its true intent. Creating a ale is quite clear and simple: When it for mental health parity was named, and new Article 35 in the Mental Hygiene comes to this issue, NAMI-NYS stands for the advocacy of Miss New York Law titled “Oversight and Regulation of firmly with science and medicine in its State Jessica Lynch who has made teen Electroconvulsive Therapy” – a title that opposition to all efforts to restrict access depression and parity in health coverage itself is telling – the bill would have de- to or ban the availability of ECT to those her platform, tremendous strides have fined as “injuries” certain common side- few who so desperately need it. ECT is been made in New York this past year effects of ECT (such as memory loss and an accepted, safe and effective medical toward passage of such legislation. apnea) and require the providers to re- treatment endorsed by the Surgeon Gen- Miss Lynch and the O’Clairs have port themselves to the State as having eral, American Medical Association, joined up with the broad coalition of “injured” such patients. The bill also American Psychiatric Association, Na- mental health advocacy organizations would have required the reporting of “… tional Institutes of Health and virtually across New York – now called TLC for any significant changes in medical con- all entities and organizations having cre- “Timothy’s Law Campaign,” including dition within fourteen days of the ad- dentials and credibility within the psy- NAMI-NYS – and have traveled the ministration of such therapy” regardless chiatric and scientific communities. Its state and its media airwaves to personal- of whether those changes were caused modern application bears little resem- ize this crucial public policy deficit and by ECT. Further, the bill seems to seek blance to it primitive precursors of dec- press for positive change. Senator Tho- only negative outcomes and did not in- ades ago, or even as recently as 10 or 15 mas W. Libous, chair of the senate’s quire if the patient actually improved or years ago. Research has led to a decrease mental health committee, introduced benefited from the therapy, which ap- in side effects and an increase in its J. David Seay, J.D. Timothy’s Law, which had already been pears also to belie the real intent behind clinical effectiveness. A recent study by overwhelmingly passed by the Assem- this information hunt. Lastly, the re- the New York State Commission on he view from Albany sees sev- bly, and garnered no less than 33 major- quired reporting would be redundant Quality of Care for the Mentally Dis- eral features on the horizon ity members as co-sponsors of the bill. with the much better-defined reporting abled (CQC) examined the administra- affecting persons with serious And the O’Clairs have met with Major- already required by the Office of Mental tion of ECT around the state. This study mental illness and their fami- ity Leader Joseph L. Bruno to ask that Health from all of its facilities and by the found that ECT is being used very cir- Tlies. They include “Timothy’s Law,” the bill be allowed to go to the floor of Department of Health’s “Statewide Plan- cumspectly and selectively and not at all efforts to restrict access to electroconvul- the Senate for a vote. They came away ning and Research Cooperative Sys- in a runaway fashion or in disregard to sive therapy (ECT), adult home reform, from the meeting “cautiously optimistic” tem” (SPARCS) which covers all Article patient consent. Opponents of ECT cite a efforts to restrict access to medications that the logjam may soon be broken. 28 hospitals, clinics and related facilities statistically insignificant number of quite through a “preferred drug list” (PDL) for NAMI-NYS salutes the O’Clairs, Jessica statewide. dated alleged abuses in their efforts to Medicaid recipients and long-term plan- Lynch, Senator Libous and Majority Governor Pataki, citing NAMI- severely restrict if not outright ban the ning for mental health housing and ser- Leader Bruno for showing courage and NYS’s concerns, and those of the New use of ECT. We are not aware of any vices. NAMI-New York State’s Board of doing the right thing for all New Yorkers York State Psychiatric Association and responsible study supporting the ex- Directors and Government Affairs Com- who suffer from mental illness and their Greater New York Hospital Association, pressed concern of opponents to ECT mittee continue to keep an eye on this families. Our hats are off to them! rightly vetoed this bill. There are efforts that it is being abused or over used. The horizon as sentinels for New Yorkers In other developments, there are some to petition the Legislature to override the CQC study found such allegations to be with mental illness. NAMI Corner fo- subtle efforts afoot to ban the use of Governor’s veto, and NAMI-NYS ada- groundless. cuses on the first two of those issues. electroconvulsive therapy (ECT) in New mantly opposes such efforts as ill- The other three issues cited at my Sadly, New York remains one of only York for that very small minority of pa- informed and mislead. In addition to column’s outset – adult home reform, a small handful of states that continue to tients who need it. ECT has evolved over misconstruing the facts about ECT and PDLs under Medicaid and the aching allow insurance companies and HMOs to the years into a safe and effective – even its present oversight and regulation, for need for serious, fair and balanced long- discriminate against persons with mental life-saving at times – medical treatment some reason the writers of these peti- term planning by OMH and the other illness by limiting coverage for mental for some serious and treatment-resistant tions also have chosen to misrepresent agencies involved with interacting with health services and charging higher co- persons with severe mental illness. Four NAMI’s position on these issues and New Yorkers with mental illness – are of payments, co-insurance and deductibles bills have been introduced and passed by disparage its reputation as an advocate no less importance to NAMI-NYS and for such benefits where they do exist. the Assembly that would, in effect, ban for persons with serious mental illness our legions of family and peer advocates. Many consider this discrimination to be access to this treatment which, in the and their families. NAMI-NYS urges its Indeed these issues will be featured in a civil rights transgression and an embar- past, has been controversial. One of the members and others not to sign such future NAMI Corners.

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A Voice of Sanity

A Column by Joshua Koerner Consumer Advocate and Executive Director, CHOICE, New Rochelle, New York

defense, no matter how deleterious its of sleep walking which, thought not par- support once “support” has been thrust, Collaboration impact may be at the moment. If this is ticularly traumatic for me, was an unwel- unwanted, upon you. not believed by the clinician, the attempt come midnight surprise for the female The answer is collaboration. As a Not Coercion at joining will be experienced by the patient whose room I walked into and journal article on cancer screening puts patient as patronizing and will heighten upon whose floor I urinated. By Joshua Koerner it, “There is a growing body of literature (not reduce) the resistance”. In light of experiences like this it’s that suggests that engaging patients to I have been treated by specialists in understandable that I stopped taking all participate in the decision-making proc- internal medicine, urology, endocrinol- medications as soon as I was no longer ess may positively influence preventa- his is how prejudice works: ogy, and orthopedics, as well as by a under anyone’s direct supervision. I lots of people are cheap, but tive health behaviors. Shared decision- prosthodontist, an endodontist and a pe- took the drugs whose side effects I knew when a Jewish person is cheap making involves a two-way exchange of riodontist. Yet there is no specialty of I could tolerate: pot and cocaine. Of information, in which both the provider they’re cheap because they’re medicine that has treated me with such course the result was more hospitaliza- TJewish. Lots of people steal, but when and the patient discuss their screening consistent patronization, condescension tions but less understanding. preferences after considering the relative an African-American person steals and contempt as has the field of mental Research states that the feelings of risks and benefits of the different options they’ve done so because they’re African health. They don’t even bother to hide the patient should not be disregarded; American. Lots of people object to and then arrive at a joint decision regard- it: it’s like we’re not only delusional but that to do so only invites further resis- treatment, but when a person with a di- deaf, dumb and blind as well. tance. Practitioners need to understand ing which option to implement. A joint agnosis of mental illness objects to treat- The first time I was confined to a why individuals do not want to partici- decision, not an imposed decision. ment it is because of the diagnosis, and locked, inpatient unit I was given medi- pate in treatment. They need to address It is so easy to tell someone else to so we have the right to override any of cation that made me feel like I was going those concerns in ways that validate disregard medication effects that include their objections and treat them anyway. to climb the walls. I could hardly sit still. them. People need to feel they are being weight gain, or lethargy, or sexual dys- That’s not only prejudice, the belief, but It was a very uncomfortable, frightening understood by their treatment profes- function. I think that every doctor in also discrimination, the action. feeling; I had no control of my own sionals if they are ever to become part- residency should be required to take In my previous column I discussed limbs. But the unit doctor was con- ners in treatment. medications that mess them up a little – how nonadherence to treatment was det- vinced it was all due to my anxiety about Genuine empathy is in short supply in make them fat and spazzy and soft. It’s rimental but commonplace: it can be being discharged. He made no secret of our current system. It simply isn’t a not the true experience, any more than found in hypertension patients, cancer his disregard for what I was saying. priority. We mental patients are all sick, living in a shelter for a few nights know- patients, transplant patients and virtually When I finally convinced him to take me the providers have all the answers, and if ing you’re going back to your apartment all other kinds of patients. As far as off the medication I felt better immedi- we don’t follow their orders...well, is the true experience of homelessness. medication adherence is concerned half ately. During episodes with other medi- there’s always Involuntary Inpatient But it would be a start. of all prescriptions filled are taken incor- cations my vision became unfocused, Commitment, Involuntary Outpatient rectly. There is strong evidence to show Even in the absence of direct experi- food tasted like metal and I was fatigued Commitment, and a whole host of other ence, the disregard of clinicians for the that resistance to treatment is a healthy and zoned out. No one ever bothered to services called Assisted and Assertive part of a person’s attempt to cope with rational desire to avoid these conse- alert me that these were possible side which really boil down to one word: serious illness, even when the pattern of quences is unjustifiable. Our mental effects of the medications I was taking. Forced. health system is forever paying lip ser- resistance is itself maladaptive. Most When I reported them I was told I Self-care requires commitment of a tellingly, attempts to override that resis- vice to evidence-based practices. There shouldn’t worry, they would go away kind other than involuntary. Recovery is tance, by force, tend to lead to even is copious evidence that treatment of any eventually, or that they weren’t impor- a day-by-day, week-by-week, and kind requires empathy, consideration, greater resistance, making forced treat- tant given the value of the drug. month-by-month process. It can never ment by mental health providers utterly partnership, shared responsibility, and After I had been hospitalized a few be imposed from without; it needs to open communication. That means shar- counter-productive. times it became evident even to my fam- develop from within. It needs to be in- ing responsibility with people who may What is productive? For an answer, I ily that I had a high sensitivity to medi- ternalized. Recovery is more than just quote from the medical journal Progress cations. When I was hospitalized in making sure someone is taking a certain in some respects be disordered or delu- in Transplantation: “Techniques such as 1986 it was my mother, and not I, who pill at a certain time each day. Recovery sional. I may have thought aliens were joining and mirroring prove indispensa- reported this to the attending psychia- is knowing your triggers, getting enough coming to transport mankind to a new ble in protecting the patient’s ego re- trist. But even she was treated with the sleep, eating right. Recovery is both a planet, but I still could recognize when sources while they develop healthier same condescension, the same attitude of process and an awareness. It’s an aware- doctors were treating me with contempt. defenses. The critical issue in joining a Please Don’t Tell Us How To Do Our ness that is teachable, but that requires The aliens are gone, but the bitterness patient’s resistance is that the clinician Job. The result: lithium toxicity, and for support and validation, not force, and it toward clinicians remained for a long has to truly believe the patient needs his the only time in my life I had an episode becomes ever more difficult to accept time.

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Preparing For The Elder Boom

By Michael B. Friedman, CSW • Based on current prevalence esti- • The current service system is, for These are not easy issues to address, mates, from 2000 to 2030 the number of the most part, structured and financed in and they cannot be addressed without older adults with mental illnesses will ways which assume that people are able substantial shifts in the way in which we grow from approximately 7 million to to leave home to go for services in spe- think about the provision of mental approximately 14 million. cialized settings despite the fact that vir- health services. It is not just a matter of tually all providers and researchers re- doing more; it requires doing things dif- • Between 2010 and 2020 alone the port a widespread need for mobile ser- ferently. It requires understanding that number of older adults with mental ill- vices. the needs of older adults are as different nesses will grow from approximately 8 from those of adults as adult needs are million to approximately 11 million. • Most older adults with mental ill- from children’s needs. nesses also have chronic physical ill- So it is not as simple as training a • During these same periods there will nesses. In part this reflects the fact that large number of geriatric mental health also be a significant increase in the pro- older adults are more likely to have professionals, pressing for more funding portion of minority older adults in the chronic illnesses, but in part it reflects an to expand services, and expanding re- United States, rising from 16.5% of the apparent correlation between mental and search. Finance, research, and the devel- elderly population in 2000 to 25.6% in opment of a well-trained, highly skilled 1 physical illness. An adequate system 2030. must, therefore, address issues of co- workforce are all essential of course, but morbidity. it will also be essential: Of course, older adults with mental illnesses are a diverse population. Anxi- • For all older adults activity and so- • to craft a new vision of service and ety and mood disorders are the most cial involvement appear to be essential support, a vision which weaves together prevalent mental illnesses. Dementia to maintaining and/or improving mental the clinical, the rehabilitative, the medi- becomes increasingly common as people health. It is, therefore, critical to pro- cal, the social, and the familial, Michael B. Friedman age. Schizophrenia may occur less fre- mote access to the social mainstream and quently among older adults than younger • to address the fissures in the current to integrate mental health services with adults.2 In addition, older adults with structure of serving older adults and to services provided through the “aging” he mental health system, which mental illnesses exhibit a wide range of bring together mental health, health, and system. currently does not serve most abilities and disabilities. Some work, aging systems older adults with mental ill- have significant personal relationships, nesses at all let alone serve and participate in community activities. • Families increasingly regard institu- Given the magnitude of other issues Tthem well, is in no way ready for the Some are unable to manage without sub- tions for older adults as an undesirable confronting the mental health system, it elder boom, which will hit in force be- stantial supports and/or are extremely last resort. Therefore, in addition to im- is easy to understand why little work has ginning in 2011. Perhaps it’s not sur- isolated. proving services in institutions, it is es- been done to begin to shape a system of prising that there has been so little prepa- Despite the heterogeneity of the sential to conceptualize and create com- care of older adults with mental health ration despite more than a decade of population, there are a number of com- munity-based support systems for older problems. But the march of demography warnings. The big hit will come outside mon issues affecting virtually all older adults who need them. is ineluctable. We must act now or face the ordinary five-year planning horizon. adults with mental illnesses. a vast crisis in the not too distant future. But the boom will be so large and will • Because families provide most of require such extensive restructuring, as • There is a vast shortage of mental the supports which older, disabled adults well as growth, that preparation cannot health professionals with expertise serv- need, it is critical to address the needs of Michael B. Friedman is the Director responsibly be put off longer. ing older adults. family caregivers as well as those for of the Center for Policy and Advocacy of whom they provide care. The Mental Health Associations of NYC Here are the facts. • Funding for mental health services and of Westchester. The Center has re- is inadequate and discriminatory. For • The rise in the numbers of minority cently begun a project to advocate for • From 2000 to 2030 the population example Medicare reimburses less for older adults makes it more and more improved geriatric mental health policy. 65 or over in the United States will grow mental illnesses than physical illnesses, important to develop culturally compe- For further information e-mail Mr. from 35 million to 70 million and from does not cover prescription drugs, pays tent services. Friedman at [email protected].

roughly 13% of Americans to 20%. for very limited home-based services, and does not cover the kinds of outreach • Research has not yet produced ulti- Footnotes: • From 2010 to 2020 the growth will and “wraparound” services that are vital mate insights or cures for mental ill- be 35%, from approximately 40 million to many people with severe psychiatric nesses among older adults. More re- 1 Estimates are from the U.S. Census Bureau to 54 million. disabilities. search is critical. 2 Surgeon General’s Report on Mental Health

Send a Message of Hope to Someone in Need With a Subscription to Mental Health News: See Page 59 PAGE 20 MENTAL HEALTH NEWS ~ WINTER 2004 the NARSAD report The National Alliance for Research on Schizophrenia and Depression

By Constance E. Lieber, President What Causes Suicide? • Alcoholism plays a role in 30 percent susceptible to suicide epidemics, which

NARSAD Most suicides happen in depressed of all completed suicides. account for between 2 – 5 percent of all people. Depression is not just a passing • Firearms are now used in more sui- suicides annually. Vulnerable youngsters exposed to stories or lyrics rich with blue mood that lifts in a few hours or cides than homicides. even a few days. It is a sadness that will suicide imagery or allusions are more • People with AIDS have a suicide risk susceptible to suicide. not go away and that interferes with eve- up to 20 times that of the general popula- ryday life. Late-Life Suicide tion. Approximately 30 percent of clini- • Clustered suicides account for 1-5 An increasing suicide rate in older cally depressed people attempt suicide. Americans is a major clinical problem. percent of all teen suicides in the United 1. Feelings of despair and hopelessness States. While people over the age of 65 make up only 13 percent of the population, they (signs of depressive episodes) are the Teenage Suicide most common motives for committing account for 25 percent of all suicides. suicide. Similar to suicidal adults, suicidal White males over the age of 85 have the youths are almost always severely de- highest suicide rate of all Americans – 2. Most depression-related suicides pressed. However, the signs of depres- six times the current overall national occur during a patient’s first three de- rate. Almost all suicides by older Ameri- pressive episodes. sion are harder to recognize in young- sters and adolescents because their sad- cans involve non-psychotic, non-bipolar 3. Otherwise ordinary events can trig- ness and despair are usually manifested depression in people who are not sub- ger depressive episodes that could lead as boredom, apathy, hyperactivity, or stance abusers. This is the most treatable form of depression. to suicide. Such experiences may include physical illness. Since youths do not Constance E. Lieber illness, humiliation, unrequited love, have the life experiences of adults, they • Approximately 15-20 percent of peo- losing money or a job, a serious domes- may react intensely to seemingly trivial ple 65 years of age and older, in the The Warning Signs Of Suicide tic quarrel, the collapse of a marriage, or frustrations. United States, suffer from depression, a death in the family. To better identify the teenagers at risk but less than half are receiving treatment.

t is estimated that there are more 4. When properly diagnosed, more than for suicide, a Columbia University re- searcher, Dr. David Shaffer, has devel- • Each year more than 6,300 older than 31,000 suicides every year in 80 percent of people suffering with de- adults take their own lives – approxi- the United States – about 11 out of pression can be successfully treated. oped a new method to screen adolescents mately 17 a day. every 100,000 people. This number for depression and suicide risk. The new Ibreaks down to about four suicides per measurement is based on a profile gener- • 75 percent of older suicide victims Contributing Factors to Suicide hour, and it is estimated that an attempt ated through computer “diagnostic inter- have been seen by their primary care is made about once a minute. The true There are many conditions that may views,” followed by treatment under physician during the month preceding numbers are probably much higher be- cause people to have suicidal thoughts, psychiatric care. Testing has shown that their death. cause many suicides are reported as acci- such as complications with marriage, young people suffering depression and Gender and Suicide pre-suicidal mood disorders will identify dents or illnesses. Suicides are usually occupation, social class, religion and Although twice as many women as the result of a complex combination of health. Other contributing factors in- themselves to the computer. emotional, social, and biological factors. clude: Children and teenagers are also more see NARSAD on page 58

NARSAD RESEARCH National Alliance for Research on Schizophrenia and Depression A Unique Partnership of Scientists and Volunteers To Conquer Mental Illness NARSAD is proud to announce the winners of the 2003 Lifetime Achievement Prizes in Psychiatric Research

The Lieber Prize For Schizophrenia Research The newly inaugurated Robin S. Murray, M.D., D.Sc., Institute of Psychiatry, London Dr. Patricia S. Goldman-Rakic Memorial Prize for The sum of his research has led to fundamental insights about the Achievement in Cognitive Neuroscience importance of early brain development in Schizophrenia, making Solomon H. Snyder, M.D., Johns Hopkins University landmark contributions to the understanding of risk factors. A pioneer in the study of brain receptors, discoverer of the role of nitric oxides as a class of neurotransmitter in the brain and techniques The Nola Maddox Falcone Prize For for understanding and manipulation of neurotransmission receptors. Affective Disorders Research Robert M. Hirschfeld, M.D., Univ. of Texas Medical Branch, Galveston The NARSAD Media Public Service Award Ross J. Baldessarini, M.D., Harvard University June Peoples and Bill Lichtenstein, Lichtenstein Creative Media Leonardo Tondo, M.D., Harvard University For their contribution to Dr. Hirschfeld is an innovative leader in the early identification and raising awareness and public understanding of mental illness. treatment of bipolar illness built on his pioneering studies of affective disorders. Drs. Baldessarini and Tondo have provided unique Honoring a NARSAD Research Partner insights into bipolar illness and the ability of lithium to improve The Renate Hofmann Trust and prevent manic depressive episodes and decrease suicidality. For its commitment to funding research to improve the lives and offering hope to those with the severe mental illnesses. The Ruane Prize for Child and Adolescent Psychiatry Research 60 Cutter Mill Road - Suite 404 Leon Eisenberg, M.D., Harvard University Great Neck, NY 11021 A leader in Child Psychiatry for over 40 years, spanning 800-828-8289 pharmacological trials, neurological and psychological theories www.narsad.org of autism and social medicine from research to teaching and social policy. Research for the Cures MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 21

The NYSPA Report

sexual world requires hiding one’s ho- Inclusive Clinical Settings when appropriate, references to signifi-

mosexuality, colloquially referred to as GLB patients are usually treated cant friends and members of nontradi- “being in the closet” or “closeted.” An- alongside heterosexual peers in inpatient, tional families during evaluation and tihomosexual attitudes are common and treatment. outpatient, and residential clinical set- reasons to hide are numerous. For ex- tings. In recent years, a few specialized When necessary, same-sex partners ample, families usually do not want to units have developed for working with and children in these families should be accept or even know that their children involved in the GLB patient’s care. For GLB persons--either community health are gay. Gay kids learn early on not to centers serving the needs of the local example, it may be important to obtain let anyone know, for fear of being GLB communities or units geared to corroborative information from partners, teased, ostracized or even physically to identify potential sources of a pa- particular problems like HIV infection or attacked. However some gay kids, those substance abuse. Whether services are tient’s problems within the context of the known as sissy boys or very masculine provided in general or specialized set- couple or family, or to include a partner tomboys, cannot hide and become tar- in maintaining compliance. In addition, tings, staff are trained about the special gets. Tragically, recent studies show gay concerns of the GLB population and to issues of confidentiality and decision- male adolescents may be three times as provide them with sensitive and unbi- making in working with heterosexual likely to attempt suicide as their hetero- families should also apply to working ased care. sexual peers. Stigma, which makes it The clinical setting and staff are im- with GLB families. difficult for gay adolescents to discuss portant determinants in creating a cli- Dr. Drescher is Chair of the Ameri- their early sexual feelings, is a probable can Psychiatric Association’s Committee mate of inclusiveness for GLB patients, contributor to this high figure. It is vital as explicit and implicit communications on Gay, Lesbian and Bisexual Concerns, that mental health services for GLB ado- of acceptance promote successful psy- author of Psychoanalytic Therapy and lescents reflect awareness of antihomo- the Gay Man (1998, The Analytic Press) Jack Drescher, M.D. chiatric treatment. For example, the sexual bias by providing accepting thera- language and behavior of psychiatrists and Editor of the Journal of Gay and peutic environments for them that do not and other staff should convey that they Lesbian Psychotherapy. further add to the stigma or trauma they do not presume all individuals or fami- Further Readings Gay, Lesbian and have already experienced. lies are heterosexual. Inquiries about Cabaj, R.P. & Stein, T.S., eds. (1996), Textbook of Bisexual Mental Health Stigma is not limited to adolescents. relationships or the gender of a patient’s Many GLB adults may be selectively Homosexuality and Mental Health. Washington, partner should be open-ended and non- D.C.: American Psychiatric Press. “out” in certain social settings, but not to By Jack Drescher, M.D., Chair judgmental. Gay-friendly publications everyone in their lives. Those who hide Duberman, M. (1991), Cures: A Gay Man’s Odys- APA Committee on GLB Concerns in the waiting area and self-reporting sey. New York: Dutton. from their families, friends, physicians, forms for patients that neutrally inquire or even their therapists, are less likely to Savin-Williams, R.C. (2001), Mom, Dad, I’m Gay: about sexual orientation and family ar- How Families Negotiate Coming Out. Washington, openly discuss and address their physical n 1948, Alfred Kinsey’s landmark rangements can help reassure a GLB DC: American Psychological Association. and mental health needs. In addition, scientific study revealed the normal person--as well as those uncertain about The preceding "NYSPA Report" deals with the many GLB individuals, seeking treat- range of human sexual diversity to their sexual orientation--that they can mental health concerns of Gay, Lesbian, and Bi- ment from health care personnel have sexual persons. It is one of a number of articles be wider than previously imagined. talk openly about their concerns. been subjected to antihomosexual bias. which will appear in this space from time to time I Kinsey’s Report eventually paved the Another important approach with Fear of stigma and actual antihomosex- addressing the special mental health issues of a way for greater acceptance of gay, les- GLB patients is to routinely include, variety of groups. ual attitudes of health care personnel bian and bisexual (GLB) people, today often result in underutilization of ser- estimated to number between three and vices by GLB adults. fifteen million Americans, or 1-5% of the population. Coming Out Determining the mental health needs New York State of this enormous population has been Many GLB individuals struggle with complicated by historical factors. the issue of whether to reveal their sex- Homosexuality, once considered a men- ual identities to others. “Coming out” or Psychiatric Association tal illness, was removed from the Ameri- “coming out of the closet” may be the can Psychiatric Association’s (APA) most commonly shared cultural experi- Diagnostic and Statistical Manual ence defining the modern gay identity. Area II of the American Psychiatric Association (DSM) in 1973. Where once homosexu- In everyday usage, this means telling ality’s treatment of choice was unsuc- another person that one is gay. Representing 4500 Psychiatrists in New York cessful efforts to change it, today’s focus However, the process is not just about is on the mental health needs of an in- revealing oneself to others. For in com- creasingly “out of the closet” GLB popu- ing out, a person attempts to integrate Advancing the Scientific lation. Some GLB mental health con- dissociated aspects of the self, to unlearn and Ethical Practice of Psychiatric Medicine cerns are briefly addressed below. the stigmatizing stereotypes of homo- sexuality, and to learn the ways of the Coping with Stigma lesbian and gay culture they are entering. Advocating for Full Parity Mental health issues affecting GLB The complex process of coming out in the Treatment of Mental Illness populations often resemble those affect- involves both internal and external di- ing heterosexual populations: develop- mensions and can lead to increased com- mental issues associated with adoles- fort with one’s own feelings. Greater Advancing the Principle that cence, psychological responses to medi- ease in expressing one’s feelings, both to all Persons with Mental Illness deserve an Evaluation cal illness, problems of aging, relation- oneself and to others, can lead to enrich- ship issues, family difficulties, or coping ment of work and relationships. Parents with a Psychiatric Physician with a psychiatric disorder. However, and mental health professionals should the stigma associated with being gay, seriously consider the special needs and to Determine Appropriate Care and Treatment lesbian or bisexual can, in many cases, vulnerabilities of GLB adolescents who either exacerbate pre-existing psychiatric are first coming out. As GLB people Please Visit Our Website At problems or affect the general mental repeatedly face moments in which they health of non-psychiatrically disturbed have to decide whether or not to reveal individuals. themselves, coming out is a potentially www.nyspsych.org A normal part of living in a hetero- ongoing and unending process. PAGE 22 MENTAL HEALTH NEWS ~ WINTER 2004 Lessons Learned The MHA Connection Mental Health Association in New York State, Inc. After Suicide 194 Washington Avenue Suite 415 By Megan Castellano, Director her whole life with depression, self inju- Albany, NY 12210 MHA in Putnam County rious behavior and numerous hospitali- Phone: (518) 434-0439 Fax: (518) 427-8676 zations as a result. I remember when I Website: www.mhanys.org met her, the scar on her neck made me wonder what her life had been like and what would make her want to do such a By Joseph A. Glazer falling through the cracks, landing on the thing. I had a lot to learn. I had just President & CEO, MHANYS street, in emergency rooms, jails, prisons taken a job as the Service Director of an and morgues. agency that provides community support We live in a climate of diminished services for mentally ill adults. I had no employment for Americans, government experience with the mentally ill. My revenue shortfalls, a shift away from gov- prior job was in a clinic that specialized ernment responsibility for our neediest in treating children and families. This and most vulnerable people. Oh, and new job I thought would be a wonderful don’t you know there is a war on? career opportunity and another chance So, the need has been recognized and for me to help people. I had no idea outlined, but at a time largely bereft of how much I would learn from the con- receptivity. The cry is loud, but so few sumers at our agency and what they decision makers want to hear it. would do to help me. We can secure passage of legislation I soon got a crash course in consumer eliminating health insurance discrimina- empowerment and what that meant for tion in neither our federal Congress nor Megan Castellano people in recovery. As I became famil- our State Senate. Our prison and jails are iar with my new duties, I immediately filled with people with serious mental connected with a young woman who illnesses – in the same proportions people was a leader, admired, loved and re- filled our state run psychiatric hospitals can still remember the phone call spected by her peers and ready willing 45 years ago. as if it were yesterday, even though and able to do whatever was needed to The Reverend Dr. Martin Luther it’s now been four years since that help other consumers, through the King, Jr., said, “Riots occur not at the awful day. My friend committed agency’s services and in her own private point of greatest despair, but at the point Isuicide and while I still have difficulty life. Her name was Renee. She would of greatest hope.” At our mental health wrapping my mind around this reality, it bubble with sunshine and had the energy Joseph A. Glazer crossroads today, it seems those points has slowly gotten less painful. It was to handle have converged. June of 1999, my friend had struggled see Lessons on page 56 Where will this path lead? Will we Mental Health at a Crossroads pass Timothy’s Law? Will we extract our folks who are caught in the criminal jus-

tice system? Will people have access to eights of attention this great the care and treatment they need? Will have not been focused on recovery become a realistic goal for all Mental Health Association mental health in twenty-five who seek it? years – since Willowbrook. As the calendar turns, we embark on in Putnam County, Inc. H President Bush has released the “New another year of government in session. Freedom Commission Report” on the We certainly have our work cut out for 1620 Route 22 state of mental health treatment in Amer- us. But we also have information and ica. The report has been traveled around support from the highest level of govern- Brewster, NY 10509 the country, well-presented by one of its ment, and the potential to make leaders authors. The document clearly outlines hear us. Next year is an election year – where America is today in meeting the for state legislators, members of Con- needs of people living with mental ill- gress and the President. Promoting a vision of recovery for individuals nesses. Such an effort, coming from the The future of our efforts lie between highest office in the land, draws needed despair and hope, apathy and riot. The and families coping with mental health issues attention to our issues. roadblocks along the way are formidable, But, here is the crossroads: The report but as 2004 approaches, we at MHANYS simply substantiates what we already find ourselves re-energized and prepared ● Peer-Run Information and Referral Warmline know. America’s mental health service to move forward. We appreciate knowing delivery system “is fragmented and in that you will continue to work beside us ● Consumer-Drop-In-Center disarray.” The gaps are bigger than the as we head down the road, looking to ● system. Our mental health structure is make our world a better place for the Peer Bridging Program failing the people it serves, and they are people we are, love and serve. ● Self-Help Groups ● Education and Support for Family Members ● Community Outreach and Education Mental Health News Wishes to Express Its Sincere Gratitude And Appreciation all of our services are available free of charge.. call us at To Our Faithful Readers, The Members Of Our Advisory Council, And The Organizations and Supporters (845) 278-7600 Who Make This Publication Possible MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 23

WORKING WITH MEDICATIONS

Do Medications Make People Fat ?

By Richard H. McCarthy whether a medication works and what its individual’s desire to eat. Likewise, me to see how fostering obesity by medi- M.D., C.M., Ph.D. adverse effects are rarely distinguish some of these medications also increase cal personnel can be construed as a pa- Comprehensive NeuroScience between desirable and undesirable a patient’s appreciation for things such tient right. Indeed, hospitals are required weight gain. As a result, every medica- as sweetness. Thus, people taking such to perform nutritional assessments and to tion that effectively treats an illness, medications may want to eat more and feed patients accordingly. Thus, patients where weight loss is a symptom, will may enjoy what they eat more than the with diabetes should not receive diets also list weight gain as an adverse effect. rest of us. So, for example, a person high in sugar. Likewise, patients who Another difficulty with the distinction taking their medication can feel hun- are obese or gaining significant amounts between desirable and undesirable grier, enjoy food more and, as a result, of weight, should not be given access to weight gain is who decides. I have yet eat more. The medication did not cause unlimited amounts of food. This failure to meet a patient with an eating disorder the weight gain, eating did. An increase to limit the amount of food made avail- who regards a return to normal weight as desire for food does not necessarily lead able to patients is a source of frustration desirable. Likewise, I have had some to weight gain. Certainly, not all pa- for the family and the physician. Later it paranoid patients that eat to purposely tients with such an increased desire gain is a problem, if not a health hazard, to put on large amounts of weight. They weight. If this person does not eat more the patient. seek to become large, if not huge, be- sweet foods, he will not gain weight, no As outpatients, people can gain cause they feel that if they are large (big matter how good it tastes. This is quite weight because they have a terrible diet. and fat) then they will be invulnerable to similar to the kind of difficulty we all In the programs that they attend and the the attacks of those whom they believe face. Chocolate tastes good but if we eat residences where they live, it is common wish to hurt them. They are confusing too much of it, we will all gain weight. for patients to be eating large amounts of “big and fat” with “big and strong”. The problem for people taking medica- not just fatty, fried foods but also foods These patients would say that their tion is that it may actually be harder for high in carbohydrates. Similarly, people weight gain is desirable, when it is really them to fight their increased desire. often underestimate the significance of a symptom of continued illness rather It may also be that patients gain fairly minor additions to the diet. One Dr. Richard H. McCarthy than of any recovery. weight in different places for different extra can of soda per day can lead to a The most frequent explanation that I reasons. A friend of mine began to look ten pound weight gain in a year. The hear from my patients is that the medica- into this issue of weight gain and found small pleasures of life, such as a candy n the past few years, the issue of tions slow down their metabolism. As a that his patients only gained weight bar, are readily available, cheap and fat- weight gain has become quite im- result, they are gaining weight even when they were re-hospitalized. In fact, tening. For those patients whose illness portant in society in general and though they are dieting and are very patients on average gained ten pounds carries with it an impairment in the abil- very much so in psychiatry. As is careful about what they eat. Unfortu- every time they were hospitalized. As ity to experience pleasure, such minor Ioften the case, problems that are com- nately, it is extremely rare for psychiatric outpatients their weight tended to remain treats may be the easiest and only pleas- mon in society at large, are magnified medications to slow down one’s metabo- stable. While they did not gain, they ure that they can find in a day. It is hard within the mentally ill community. Pa- lism to this degree. The problem is more also did not lose the hospital acquired to lose weight with a diet high in fats, tients can and do gain weight while tak- often not that our glands are being weight. Therefore, their weight went up carbohydrates and fried food. However, ing medications. The question is are the slowed down, but that we are eating every time they were hospitalized. What these foods are easy to obtain and almost medications causing people to gain more than we think we are eating. When was happening in the hospital that would always cheaper than those foods that are weight, and if not, why does this occur? I ask people to record what they eat and lead to such significant gains in weight? necessary for a healthy, weight reducing Even though it seems simple, it is not add up the calories, it is almost always In general, it has been my observation, diet. Fruits and vegetables are much so easy to decide if a medication causes the case that they are taking in far more that patients are overfed in the hospital. more expensive than pasta. To some weight gain, and if that weight gain is than they think they are. People, not just This overfeeding has three separate extent, the inadequate diets of outpa- bad. In many psychiatric illnesses, the mentally ill, often under report their sources. First of all, the patients them- tients is due not just to the decisions weight loss is a symptom. This is not food intake and only become aware of selves will often seek treats such as soda true just for those with eating disorders. just how much they are eating when they and candy and obtain them more often about food made by the patients and Weight loss is a typical symptom of de- actually count calories. Moreover, peo- than they would have on the outside. staff, but also to the amount of money pression. Manic patients can burn off ple often confuse “fat free” with “low This may be due to boredom as much as made available for this purpose. Poorly amazing amounts of weight in the course calorie”. These are quite different. It is anything else. I have never been to a funded programs will feed patients of a manic episode and weight loss is not unusual for a “fat free” food to have hospital that did not have a candy and poorly and the programs outside the hos- frequently found in psychotic disorders more calories than the regular food. soda machine that patients could use. pital that house and treat the patients are as well. As these patients improve, their Thus, people may think that they are Secondly, visitors often bring food to poorly funded. weight goes back up to what it had once dieting with fat free when they are really give to the patient in an attempt to help Weight gain occurs in everybody been. overeating. When people say that they the person feel better. Food feels nice, when the daily caloric intake is greater A better way to discuss weight gain gain weight because of a gland problem and people in the throes of a hospitaliza- than the amount the person burns off. In would begin not so much as to whether it they are partially correct. The major tion have little else that is nice in their patients who are sedated, it is not sur- occurs, but whether the weight gain is gland that is responsible for gaining lives. Thirdly, hospitals often over feed prising that exercising goes down. It is desirable or undesirable A return to weight is the “mouth gland.” My pa- patients. Hospitals allow patients either possible for medications to sedate people normal weight in a depressed patient tients and I gain weight and get fat for almost unlimited food or inordinately such that they exercise less and in this who is recovering is desirable. Contin- the same reason; we eat more than we large portions. In the past, every time way medications may very well lead to ued weight gain above and beyond what burn off through exercise. What is dif- that I proposed that the hospital place weight gain. The solution here is for the they had been before the onset of their ferent for people taking medications is some kind of a limit on the amount of individual to seek less sedating medica- episode of illness is usually considered that they often want to eat more and they food a patient could get at lunch, the tion and/or to increase activity. to be undesirable. The desirable weight frequently exercise less. proposal was turned down. I routinely Blaming all weight gain on medica- gain has less to do with the medication It is not entirely fair that people tak- saw patients eating two main course and tions is as silly as expecting medications and more to do with recovery. The un- ing medications for their mental illnesses three deserts for lunch. In some hospi- to completely solve all of the person’s desirable weight gain may be related to have more to struggle against than eve- tals, it is argued that “second helpings” problems. Medications alone do not lead the medication or to recovery. It’s ryone else. Almost all psychiatric medi- are a patient’s right and any attempt to to recovery. Hard work does. Medica- sometimes hard to tell. Unfortunately, cations, especially all those medications limit them is an attempt to deprive an tions alone do not make you fat. Over studies that are used to determine used to treat psychosis, will increase an individual of his rights. It is difficult for eating and under exercising does. PAGE 24 MENTAL HEALTH NEWS ~ WINTER 2004

AAS from page 14 veloping training curricula for men-

tal health professionals. • Improving and expanding surveil- • developing training materials for the American Association of Suicidology

lance systems to better identify risk U.S. Army’s and the Department of factors and protocols for data collec- the Navy’s suicide prevention pro- ELDERLY SUICIDE FACT SHEET tion grams;

• certifying and networking crisis How is the AAS leading the effort hotlines into a 1-800-SUICIDE na- • While the elderly make up only 12.6% of the population, they account for of prevent future suicides? tional crisis intervention system and almost 18.1% of the suicides.

evaluating the process and outcomes The American Association of Suici- • There is one elderly suicide every one hour thirty-nine minutes. of telephone hotline interventions; dology (AAS) was founded in 1968 as a • The suicide rate for the elderly rose 9% between 1980 and 1992. During that national/international membership or- • providing supportive resources and directories of support group services rime, there were 74, 675 completed suicides of persons over 65. Rates have ganization committed to better under- declined since that time. stand and prevent suicidal behaviors. As for survivors of suicide; the oldest of national non-profit organi- • developing recommended protocols • In 2000, suicide rates ranged from 12.6 per 100,000 among persons aged 65 zations, AAS has a storied history in the and interventions to prevent suicide to 74, to 17.7 per 100,000 persons aged 75 to 84, which is nearly double the in correctional systems; overall U.S. rate. field of suicidology. It publishes a highly respected peer-reviewed journal • networking clinician-researchers • White men over the age of 85 are at the greatest risk of all age-gender-race (Suicide and Life-Threatening Behavior) and public health professionals with groups. In 1999, the suicide rate for these men was 59.6 per 100,000. That in the field, presenting state-of-the-art survivors and others to constantly is nearly 6 times the current overall rate. research on suicide and evaluations of improve systems of care and inter- prevention programs. It informs the pub- vention with at-risk individuals, etc. • 84% of elderly suicides are men; the number of men’s suicides in late life is 5 times that for women (men’s rates are 7.6 times those of women). lic and the professional communities of What are our greatest challenges? current national and international devel- • The rate of suicide for women declines after age 60 (after peaking in middle What lies ahead? opments through a quarterly newsletter adulthood, age 40-54). (Newslink) and publishes yet a second Suicidology is a young field (only newsletter written solely by and for sur- • Although older adults attempt suicide less often than those in other age slightly more than 100 years old as a vivors of suicide (Surviving Suicide). In groups, they have a higher completion rate. The elderly are more lethal in “scientific” area of inquiry). As it took addition, for the past 35 years AAS has their attempts and complete suicide more often. For all ages combines, there more than 200 years to eradicate small- administered an annual conference for is 1 suicide for every 20 attempts. Among the young (15-24 years) there is 1 pox, the cause of that was a single viral mental health clinicians and researchers, suicide for every 100-200 attempts. Over the age of 65, there is 1 suicide for entity, we have a great deal to yet learn public health professionals, survivors, every 4 attempts. about such a complex problem. and front-line crisis workers and crisis From a research perspective we need • Firearms are the most common means of completing suicide among the eld- service professionals, offering intensive to implement large-scale prospective erly. Men (78%) use firearms more than twice as often as women (35%). training opportunities and state-of-the-art studies of at-risk individuals. We need research updates. • Alcohol or substance abuse plays a diminishing role in later life suicides. to no longer exclude the most at-risk individuals from randomized clinical • Contrary to popular opinion, only a fraction (2-4%) of suicide victims have Moreover, the AAS has established trials of new interventions. We need been diagnosed with a terminal illness at the time of their death. Two-thirds leadership positions by: greater emphasis on outcome evaluation of older adults in their late 60’s, 70’s and 80’s were in relatively good physical health when they died by suicide. studies of prevention initiatives. We • advocating for the National Violent need a better understanding of why phar- • 20% of elderly suicides over 75 have been seen by a physician within 24 Death Reporting System, now macologic interventions work for some, hours of completing suicide; 35% have been seen by a physician within a housed at the CDC to better collect but not others. We need to better under- week; 75% have seen a primary care physician within a month of their sui- data regarding suicidal and homi- stand pathways of psychological pain cide; and 80% have seen a primary care physician within 6 months of their cidal-suicidal behaviors; and mechanisms for helping people bet- suicide. ter tolerate and cope with such aversive • developing recommendations to experiences. • 66%-90% of elderly suicides have at least one psychiatric diagnosis. Two- prevent youth suicide by firearms; From a public health perspective we thirds of these diagnoses are for late-onset, single episode clinical depres- sion. recommendations to inpatient psy- need to better educate the public that chiatric services regarding discharge suicide is much more complex than sim- • As many as 75% of depressed older Americans are not receiving the treat- disposition planning for suicidal ply an outcome of depressive illness. ment they need, placing them at an increased risk of suicide. patients and their families; We need to understand better how to • conducting studies designed to in- motivate men to seek and accept receiv- • Elderly persons are less likely to reach out by calling a crisis line than their younger counterparts. crease help-seeking behavior among ing help. We need to better educate suicidal males; families that a gun in the home is much • Suicide rates are highest in the mountain states of the United States for the • publishing collaborative recommen- more a threat to those that live in that nation as a whole and the elderly. dations for the media reporting of home, particularly youth, than it is a deterrent to unwanted intrusion. We suicide; MYTHS: • defining research-based recommen- need dramatically increased infusions of federal and private funding to wage dations for the identification and 1. Depression among the elderly is a normal consequence of aging and “war” on suicide. We need to reduce dissemination of appropriate public associated problems. health messages, e.g., on the Warn- barriers to effective treatment, particu- larly managed care controls on covered 2. Depression among the elderly cannot be treated. ing Signs of Suicide; systems of care and parity in insurance 3. Most completed suicides are terminally ill. • collaborating on research projects in coverage for underlying mental disor- the states of Nevada and Alaska 4. Elders who complete suicide do not have close family members. ders. which have led the nation in suicide Clinically, we need to develop a 5. Only elderly persons who live alone are at risk for suicide. rates. The AAS is currently work- range of new and creative models of 6. Suicide and suicidal behavior are normal responses to stresses experienced ing with colleagues in Alaska to intervention. We need to better train by most people. intensively study and profile all sui- clinical and primary care professionals to cides in the state in the last year; 7. There is nothing that can be done to stop an elderly suicide. assess risk and treat (or refer for treat- • training thousands of mental health ment) at-risk individuals. We need to 8. Most suicidal elders will self-refer to obtain mental health care. professionals in risk assessment and better treat individuals to contain aggres- 9. Suicidal elderly do not exhibit warning signs of their suicidal ideation or intent. treatment protocols for working sion, tolerate frustration, regulate painful with at-risk individuals; emotions, and cope with hurtful experi- 10. Adverse living conditions are not significant risk factors in elderly suicide. • developing core curricula for state ences. We need better attention to conti- and community suicide prevention nuity of care. We need to listen better to In this fact sheet, elderly refers to persons over the age of 65. Information task force and committee personnel suicide survivors as they share their ex- periences with clinical care systems. presented refers to the latest available data (i.e., 2000 data). to better form effective coalitions to prevent suicide on local levels; de- see AAS on page 42 MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 25

PAGE 26 MENTAL HEALTH NEWS ~ WINTER 2004

NIMH from page 1 behavior. As with people who die by sui- cide, many people who make serious sui- or sexual abuse; firearms in the home; in- cide attempts have co-occurring mental or American Association of Suicidology carceration; and exposure to the suicidal substance abuse disorders. The majority of behavior of others, including family mem- suicide attempts are expressions of extreme bers, peers, or even in the media. distress and not just harmless bids for atten- UNDERSTANDING AND HELPING THE SUICIDAL PERSON tion. A suicidal person should not be left Gender Differences (Chart Below) alone and needs immediate mental health Be Aware of the Warning Signs treatment. Adverse life events in combina- Suicide was the 8th leading cause of tion with other risk factors such as depres- There is no typical suicide victim. It happens to young and old, rich and poor. death for males and the 19th leading cause sion may lead to suicide. However, suicide Fortunately there are some common warning signs which, when acted upon, of death for females in 2000. More than and suicidal behavior are not normal re- can save lives. Here are some signs to look for: four times as many men as women die by sponses to stress. Many people have one or suicide, although women report attempting more risk factors and are not suicidal. Other A suicidal person might be suicidal if he or she: suicide during their lifetime about three risk factors include: prior suicide attempt; times as often as men. Suicide by firearm is family history of mental disorder or sub- the most common method for both men and stance abuse; family history of suicide; • Talks about committing suicide women, accounting for 57 percent of all family violence, including physical or sex- • Has trouble eating or sleeping suicides in 2000. White men accounted for ual abuse; firearms in the home; incarcera- • Experiences drastic changes in behavior 73 percent of all suicides and 80 percent of tion; and exposure to the suicidal behavior • Withdraws from friends and/or social activities all firearm suicides. of others, including family members, peers, • Loses interest in hobbies, work, school, etc. or even in the media. Children, Adolescents, • Prepares for death by making out a will and final arrangements and Young Adults Prevention • Gives away prized possessions • Has attempted suicide before In 2000, suicide was the 3rd leading Preventive efforts to reduce suicide • Takes unnecessary risks cause of death among 15- to 24-year-olds— should be based on research that shows 10.4 of every 100,000 persons in this age which risk and protective factors can be • Has had recent severe losses group—following unintentional injuries and modified, as well as which groups of • Is preoccupied with death and dying homicide. Suicide was also the 3rd leading people are appropriate for the intervention. • Loses interest in their personal appearance cause of death among children ages 10 to In addition, prevention programs must be • Increases their use of alcohol or drugs 14, with a rate of 1.5 per 100,000 children carefully tested to determine if they are safe, in this age group. The suicide rate for ado- truly effective, and worth the considerable What To Do lescents ages 15 to 19 was 8.2 deaths per cost and effort needed to implement and 100,000 teenagers, including five times as sustain them. Here are some ways to be helpful to someone many males as females. Among people 20 Many interventions designed to reduce who is threatening suicide: to 24 years of age, the suicide rate was 12.8 suicidality also include the treatment of per 100,000 young adults, with seven times mental and substance abuse disorders. Be- • Be direct. Talk openly and matter-of-factly about suicide. as many deaths among men as among cause older adults, as well as women who • Be willing to listen. Allow expressions of feelings. Accept the women. die by suicide, are likely to have seen a feelings. primary care provider in the year prior to Older Adults their suicide, improving the recognition and • Be non-judgmental. Don’t debate whether suicide is right or treatment of mental disorders and other wrong, or feelings are good or bad. Don’t lecture on the value of Older adults are disproportionately likely suicide risk factors in primary care settings life. to die by suicide. Comprising only 13 per- may be one avenue to prevent suicides • Get involved. Become available. Show interest and support. cent of the U.S. population, individuals age among these groups. Improving outreach to • Don’t dare him or her to do it. 65 and older accounted for 18 percent of all men at risk for suicide is a major challenge suicide deaths in 2000. Among the highest in need of investigation. • Don’t act shocked. This will put distance between you. rates (when categorized by gender and race) Recently, the manufacturer of the medi- • Don’t be sworn to secrecy. Seek support. were white men age 85 and older: 59 deaths cation clozapine received the first ever • Offer hope that alternatives are available but do not offer glib per 100,000 persons, more than five times Food and Drug Administration indication reassurance. the national U.S. rate of 10.6 per 100,000. for effectiveness in preventing suicide at- • Take action. Remove means, such as guns or stockpiled pills. tempts among persons with schizophrenia. Attempted Suicides Additional promising pharmacologic and • Get help from persons or agencies specializing in crisis intervention and suicide prevention. psychosocial treatments for suicidal indi- Overall, there may be between eight and viduals are currently being tested. Be Aware of Feelings 25 attempted suicides for every suicide If someone is suicidal, he or she must not be left alone. Try to get the person to seek death; the ratio is higher in women and Many people at some time in their lives think about committing suicide. Most youth and lower in men and the elderly. help immediately from his or her doctor or Risk factors for attempted suicide in adults the nearest hospital emergency room, or call decide to live, because they eventually come to realize that the crisis is include depression, alcohol abuse, cocaine 911. It is also important to limit the person's temporary and death is permanent. On other hand, people having a crisis use, and separation or divorce. Risk factors access to firearms, medications, or other sometimes perceive their dilemma as inescapable and feel an utter loss of for attempted suicide in youth include de- lethal methods for suicide. control. These are some of the feelings and things they experience: pression, alcohol or other drug use disorder, from In Harms Way: Suicide in physical or sexual abuse, and disruptive America, found at www.nimh.nih.gov • Can’t stop the pain • Can’t think clearly • Can’t make decisions • Can’t see any way out • Can’t sleep, eat or work • Can’t get out of depression • Can’t make the sadness go away • Can’t see a future without pain • Can’t see themselves as worthwhile • Can’t get someone’s attention • Can’t seem to get control

If you experience these feelings, get help! If someone you know exhibits these symptoms, offer help and contact:

• A community mental health agency • A private therapist or counselor • A school counselor or psychologist • A family physician • A suicide prevention or crisis center MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 27

Depression and Suicide:

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LSome religious traditions (such as Ti- It is pain which often leads us to say, betan Buddhism) adhere to the belief “Oh God, can you help me.” How many ARTWORKS is currently seeking individuals with disabilities in- that a human life is an extremely rare of us say “Oh, God, thank you” for the terested in obtaining vocational training in graphic arts, computerized de- and wonderful opportunity; an opportu- “routine” miracles of our daily exis- sign, and sales and management skills, as well as artists with special needs nity to grow and learn how to love one- tence: the ability to breathe, move our self and others. Even with 8 billion hu- bodies painlessly, see, hear, taste, touch, who wish to sell their art and crafts on consignment. mans populating the planet, many be- smell, think, communicate? Only when Contact Cristina Boardman for details. lieve that each human life has the poten- we lose one of these “givens” do we Sponsored by Verizon tial for amazing growth and accomplish- place true value upon them. A popular ment. song of the Sixties (and again, today) Nevertheless, life sometimes appears has as it’s main verse “Don’t it always Wednesdays, Fridays, to be drab, hopeless, and worthless to a seem to go, you don’t know what you’ve Saturdays & Sundays: large percentage of us every day. got till it’s gone?” May we appreciate 12 PM—5 PM (According to some estimates, as many the many gifts we have while we have Thursdays: 2 PM—7 PM as one in twenty individuals suffers from them, in all their abundance. depression for a significant amount of How is it that so many people suffer 628 Mamaroneck Ave. time in any given year.) No one ever from depression? And how is it that so Mamaroneck, NY said that the journey would be easy; many people in the midst of depression every life contains some suffering, yet act upon the self destructive and suicidal (914) 632-7600 x 220 pain and suffering can be great teachers. thoughts and feelings that they experi- [email protected] If not for pain, many of us might fall ence? How is it that so many individu- prey to living dull and lazy lives, revel- als who suffer extreme depression are The Guidance Center is a health and human services organization that provides ing in our so called accomplishments able to hang on? All thoughts and feel- services to individuals with disabilities.. Artworks is a Guidance Center vocational program. and achievements, thinking ourselves ings are temporary, superior because we have achieved a see Eastern on page 57 Helping Families Heal From Suicide

By Dr. Brenda Shoshanna largely from this. There is not only sur- person would have liked you to do. vivor guilt, but the feeling that the per- Author and Lecturer • What would you really have liked to son died because a family member did do? What, realistically, could you not love them enough, or give ade- have done? hen there is a suicide, the quately in the past. Past difficulties in victim is not only the one the relationship now surface to be re- • Notice the differences and similari- who has perished, but it’s solved. This in itself may be quite hard ties between the three lists.

W as if the entire family net- to handle. • Now, go on. What has the person work has too. The individual and their It is crucial to realize that guilt is a not yet done for you that you still family are inextricably interconnected, toxic force that erodes one’s ability to wanted him to do? when we touch one part, the other feels work through issues. It also damages the • Write it down. Make a list. it. The entire constellation must now be quality of one’s life. All interaction that attended to. In order to do this effec- arises from guilt inevitably goes the Go over each list. Forgive yourself tively, it is crucial not only to deal with wrong way. It never produces the kind of for what you could not yet do. Forgive the enormous guilt each member is feel- satisfaction and comfort we are in real the person who died for not fully giving ing but to truthfully understand the fam- need of. to you. ily dynamics that have been going on. By opening the way for family mem- Now, see if it is possible for you to Along with dealing with the suicide, bers to become aware of, accept and give what has been ungiven to someone other family issues often arise. even express their feelings, a great deal who is still living. (This may be difficult Within the family, there may now be of good can be done. The family mem- Dr. Brenda Shoshanna in the beginning, but as time goes on it is a strong expectation that other family bers will no longer feel so alone. They a great source of healing. It allows our members will love and support each will see that these feelings are natural relationship with the deceased to be a other in a way they may never have been comply, not only is there guilt within, and that they can be resolved. This, in source of growth for ourself and good- able to before. In fact there is often an but they may risk censure from the entire itself, is very healing. They may grow to ness for others.) implicit demand by some that others family as well. It is very important to see that guilt is unnecessary, that they After this is done many have noticed come through for them, (terrible pressure bring this dynamic to light. Once it is did all they could at the time. that it is much easier to be at peace with can be placed on surviving children by looked at and discussed, a great deal of There is a wonderful process for a themselves. parents in cases like these). pressure may subside for all. family to use to help deal with guilt: Expressing Resentment Carefully But a family member may not be able Undoing Guilt Process to come through for many reasons of While guilt may be common in some their own. There may have been difficult Anything that helps dissolve the pres- • What have you not yet done for the cases, fury and resentment rage on in or ambivalent relationships in the past. sure of guilt is a crucial adjunct to person who died that you feel you others. A great deal of unresolved anger Now they are suddenly being called health. Unfortunately, when a suicide really should have done? and animosity comes out in a family at a upon to give love that they just do not takes place, guilt is a predominant reac- time like this. • Write it down. Make a list. feel. tion and initially, much of the interaction However, if an individual does not between family members may stem • Now, write down what you think the see Helping Families on page 54 PAGE 28 MENTAL HEALTH NEWS ~ WINTER 2004 In The News...at the Office of Mental Health News

Verizon NY Adds Mental Health News Board Chairman Announces Grant To Employee Charitable Deductions List From the Bristol-Myers Squibb Company

Staff Writer nity, and Mental Health News is provid- Staff Writer Mental Health News ing an outstanding source of mental Mental Health News health education and hope to thousands of individuals and families through its he holiday season is a time of award winning quarterly publication,” The Bristol-Myers Squibb Company of giving, family, and community said John F. Butler, Regional Manager Princeton, New Jersey has just awarded spirit. That spirit is evident as for Community Affairs. “I wanted to a generous charitable education grant to well at Verizon New York, the have Mental Health News added to our Mental Health News. The announce- Tregions largest telecommunications cor- web list of charitable organizations so ment was made by Dr. Alan B. Siskind, poration. that Verizon employees who support Chairman of the Board of Directors of Several years ago, the Verizon Foun- mental health causes can help this wor- Mental Health News Education, Inc., the dation launched "Verizon Volunteers," thy organization.” parent organization to the publication. an employee volunteer program that According to Ira H. Minot, Mental “This grant by the Bristol-Myers provides matching funds for nonprofit Health News founder and publisher, Squibb Company represents an out- agencies and encourages employees to “John Butler exemplifies the wonderful standing effort by a leading manufac- spend more time and resources helping spirit and involvement that Verizon New turer of psychopharmacological products the agencies they care about the most. York has with so many local and state- to recognize the vital mental health edu- Verizon Volunteers gives employees the wide organizations in our region. He cation mission of our organization,” opportunity to donate funds to the non- has continually helped to inspire my stated Siskind. profit agencies of their choice by simply efforts to bring Mental Health News to The funds will help to expand the visiting the company’s website and more and more people, and we truly organization’s ability to continue to choosing from a list of worthy causes. appreciate this recognition as a newly build the organization’s capacity to “Mental health organizations are a listed organization in Verizon’s em- reach more individuals and families af- Dr. Alan Siskind vital part of the fabric of our commu- ployee giving program.” fected by mental illness. Mental Health News 2003 Campaign Raises Vital Funds

Staff Writer Mental Health News Mental Health News 2003 Honor Roll

his year marked the first effort by Mental Health News to actively seek charitable gifts to Winifred Balboni Dr. Robert M. Lichtman help support its vital and ever Tgrowing mental health education mis- Helene Barsky Ann Loretan sion. Several months ago letters went Barbara Bartell Dr. Michael & Jan Minot out requesting donations to the organiza- tion’s Fall 2003 Annual Appeal. In ad- John C. Becker Donald Morris dition during the past year, the organiza- tion received support from the West- Joseph Bonaro Nami Familya of Rockland chester and Orange County Department of Mental Health, a Management Assis- John Butler NYSPA tance Program Grant by the United Way Lois L. Cowan Orange County DMH of New York City, a gift from the Rita J. and Stanley H. Kaplan Family Founda- C. Deborah Cross, MD Barry B. Perlman, MD tion in New York City, and the just an- nounced grant from the Bristol-Myers Joan Fabricant Stephen Rogowsky Squibb Company. Janet Z. Segal, C.S.W. “Our entire Board of Directors joins Rena Finkelstein Valerie Salwen me in expressing our pride in this young the APA Area Councils, this award rec- Rick & Deane Finnan Dr. Newton M. Schiller organization’s progress and the generous ognizes outstanding recent current activ- support that the community has given to ity and contributions in the field of psy- Leonard Forchheimer Joanne Schwartz help us continue to provide and expand chiatry and mental health. A generous our vital connection to people with men- donation, funded by an annual grant Luisa Francoeur Jan & John Segal tal illness,” stated Janet Z. Segal, from McNeil Pharmaceuticals accompa- Susan Frederick Francine Shorts C.S.W., Vice-Chairman of the Board of nied the award which was presented to Mental Health News Education, Inc. Minot by NYSPA President, Barry Dr. Marsha Hurst Dr. Alan B. Siskind In addition to the excitement gener- Perlman, M.D. ated by the outpouring of support during In an effort to give added recognition R.J. & S.H. Kaplan Foundation Bristol-Myers Squibb Campaign 2003, the New York State to supporters of the annual campaign for Psychiatric Association has just awarded Mental Health News Education, Inc., we Samuel C. Klagsbrun, MD United Way of New York City its 2003 Warren Williams Award to have compiled the following Honor Roll, Andrea Kocsis Westchester County DCMH Mental Health News Founder and Pub- and will continue to add names as they lisher, Ira H. Minot. Administered by come in for this and future campaigns. A WINTER 2004 ADVERTISING SUPPLEMENT SPONSORED BY FOUR WINDS HOSPITAL PAGE 29 FOUR WINDS HOSPITAL “Celebrating 25 Years Of Caring, Healing and Clinical Excellence”

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How The Body Speaks: Eating Problems, Self-Mutilation, Body Modifications

By Sharon Klayman Farber, Ph.D. adolescents and of those whose need to wonder what terrible sor- bodies had been abused. Not sur- rows cannot be spoken. When food prisingly, those with eating disor- that had tasted good suddenly oday, increasingly more ders and those who mutilate them- feels like poison and has to be people are “coming out” selves or become “addicted” to the purged from the body, we should about their self-mutilating pain of piercing or tattooing have wonder what traumatic experiences behavior in much the suffered considerable trauma in exist that cannot be contained, me- T childhood, including separations tabolized, and integrated. One same way that people began to “come out” about anorexia nervosa and loss, family violence, physical needs to decode the bodily narra- and bulimia in the 1970’s. Cutting or sexual abuse, coercive and intru- tive in order to understand the mys- is only part of a spectrum of self- sive medical and surgical proce- terious paradox and power of self- mutilating behavior. Other forms dures, and the more ordinary every- harm. include burning, scratching, needle- day trauma of being ignored, emo- When the body speaks, the key sticking, hair-pulling, and severe tionally neglected, and robbed of a questions to ask are: To whom is nail and cuticle biting and others. sense of self. Above all, they suffer the body speaking? What is the In addition, we are seeing a variety from painful and traumatic attach- body saying? of body modifications, passive self- ments to the earliest and most im- Trauma has been described as mutilation in which a person en- portant people in their lives, repeat- the experience of feeling ourselves Sharon Klayman Farber, PhD. gages another to pierce, brand, cut, ing the trauma in their self-harm. to be utterly and completely alone. or tattoo his or her body. Self- Pain is a very subjective thing. And it is the human attachment to mutilation is more of a problem When we have to tolerate the pain Herman, who has studied trauma another human being that saves us. than has been thought, and my own of a medical or dental procedure, has said, “The conflict between the Under the best of circumstances, research has found that it often co- we might find ourselves digging will to deny horrible events and the such an attachment can occur in exists with an eating disorder and our nails into our hands, thus di- will to proclaim them aloud is the psychotherapy. There has been a serves many of the same psycho- verting ourselves from the pain of central dialectic of psychological problem, however, in self-harming logical functions. the procedure by inflicting another trauma.” But denied or dissociated people finding psychotherapy that Those who harm themselves in kind of pain on ourselves. It feels experience has a power of its own. is really helpful. First of all, many these ways struggle with issues of better to control one kind of pain Like food that is stuck in the throat, people who harm themselves have body boundaries and ownership of than feel to feel controlled by an- the experience must be chewed, had painful, even traumatic experi- the body, such as: How much space other kind. So rather than feeling swallowed, digested and metabo- ences with mental health profes- does my body take up? What is in- like the passive victim of others lized or the body will try to dis- sionals, and are wary and distrust- side it? How does it work? How who preyed upon them or failed to charge it physically. The body will ful. Second, it is no secret that most does it feel? Does it belong to me? protect them from harm, they in- exercise madly, binge, purge, psychotherapists are equally wary Or does it belong to my mother, flict physical pain on themselves, a starve itself, cut or burn itself, or and anxious around self-harming father, spouse or partner, to do with welcome diversion from emotional get itself tattooed or pierced repeat- patients. Our training has not pre- what they wish? There is a sense of pain. edly. When the voice is silenced by pared us for patients who take po- being alienated from their own Traumatic events may involve trauma, all that will emerge are tentially life-threatening risks. Pa- bodies, which makes it easy to treat real or perceived threats to ones such gestures. When the body at- tients who harm themselves may their bodies as a thing, and thus life, evoking terror, helplessness, tacks itself with a blade, this is a evoke intense feelings of anxiety abuse their bodies. And many peo- and the fear of annihilation. One is gesture that should make us wonder and helplessness, at times even an- ple who do these things to them- left feeling utterly powerless, with- to whom the body is speaking and ger in therapists, who may insist selves do it to claim ownership of out any sense of control, meaning, for whom the rage is meant. When that their body, a common concern of and human connection. Dr. Judith the body weeps tears of blood, we see Body Speaks on page 30

Four Winds Hospital is the leading provider of Child and Adolescent Mental Health services in the Northeast. In addition to Child and Adolescent Services, Four Winds also provides comprehensive Inpatient and Outpatient mental health services for Adults, including psychiatric and dual diagnosis treatment. PAGE 30 A WINTER 2004 ADVERTISING SUPPLEMENT SPONSORED BY FOUR WINDS HOSPITAL harm. One needs to know that de- her to understand and articulate spite the sometimes life-threatening this, the conviction about this gives nature of the self-harm, it may be the patient a new and welcome idea more about living and surviving about herself, one that emphasizes than about dying. That is, it may be something good and healthy in her. the patient’s best attempt to keep The aim of treatment is to help from hurtling into the abyss of sui- the patient develop the ability to cide or psychosis. The physical define, tolerate, think about, and pain they inflict upon themselves regulate her emotional states so that diverts them, at least momentarily, she does not have to rely upon hurt- from their emotional pain, and so ing herself for self-regulation. The they crave it, developing an addic- aim is to help the patient move tive-like relationship to self-harm. from the language of the body to Yet when a patient’s behavior expressive spoken language. So endangers his physical safety, this instead of harming herself, she is an issue that must be addressed. might become able to say, “I feel Therapists need to help patients angry” or “guilty” or “sad” or become responsible enough for “ashamed” or “frightened”. Devel- their own physical safety so that oping the ability to use words in the therapist need not fear for the this way is a tremendous achieve- patient’s life. No therapist can be ment. calm and thoughtful enough to treat We all feel bad at times. It is a patient on an out-patient basis if part of the human condition. When he has real reason to worry that the one can speak to another about the patient might seriously hurt himself chaos of emotions churning around or die. Until the patient can assume inside, using words provides a greater responsibility for his physi- sense of order to what had previ- cal safety, a more structured level ously felt chaotic, and can trans- of care such as inpatient or day form depression and numbness into hospital treatment may be neces- feeling and reflection. Having sary. someone there to listen and try to A sense of emotional safety understand makes it less lonely, in the relationship with the thera- and the feelings become more tol- pist is something that takes time to erable. And when this happens, develop. If the patient can find a there is less need to harm oneself. safe harbor with her therapist, this is an enormous achievement. At a time when so many people feel that Sharon Klayman Farber, PhD. there is nobody there for them, hav- is a Board Certified Diplomate in ing a therapist who is reliably there clinical social work in private and emotionally available can be- practice of psychotherapy with gin to turn the tide. To have no- children and adults in Hastings-on- body there means that they must Hudson, NY. She is the founder of rely on themselves, and so, not Westchester Eating Disorders Con- knowing what else to do, they turn sultation Services. She is on the in desperation to their own bodies. faculty at the Cape Cod Institute. They may consider themselves She is the author of When the Body sick, hopeless, and beyond help. If Is the Target: Self-Harm, Pain, and we consider that self-harm devel- Traumatic Attachments (Aronson Body Speaks from page 29 like a battle for control, and may ops as a survival tool, then of 2000, 2002). Dr. Farber offers in- ultimately fail. course there is nothing sick about dividual and group consultation the patient simply stop. Many If those of us in the mental trying to survive severe psychic and in-service training to mental therapists have little understanding health professions can overcome trauma. If the therapist can let the health professionals who treat self- of how precious these behaviors our fear of knowing about the dark- patient know from the outset that harming patients, and hopes to de- can be, and how trying to take them est, most destructive part of the self she must have good reasons for her velop a supportive network of such away only makes the patient feel that exists in some measure in all of behavior even if she cannot articu- therapists. She can be reached at that the therapist is trying to control us, we can come to understand late what they are, that the therapist (914) 478-1924. Website: him. Treatment may come to feel more about the language of self- will work together with her to help www.Drsharonfarber.com.

“Celebrating 25 Years of Caring, Healing and Clinical Excellence” 800 Cross River Road, Katonah, New York 10536 914-763-8151 www.fourwindshospital.com A WINTER 2004 ADVERTISING SUPPLEMENT SPONSORED BY FOUR WINDS HOSPITAL PAGE 31

Oppositional Defiant Disorder

By Barbara Greenberg, Ph.D. tures of the disorder vary as a func- thrown by their parents, teachers, tion of the individual’s age and se- or other authoritative adult figures verity of symptoms. In the pre- who they feel do not understand re you “afraid” to come school years, warning signs include them. These children often feel, home from work in the high reactivity, and difficulty being but cannot articulate, that their par- evening? Is your house soothed. During the school years, ents are not attuned to their needs A filled with tension due children may experience low self- and feelings. to a constant struggle with every- esteem, mood lability, low frustra- Oppositional symptoms often thing having to do with your ado- tion tolerance, swearing and the emerge in the home setting rather lescent? Do you frequently feel precocious use of alcohol, tobacco, than at school, or during activities incompetent in your own home? or illicit drugs. It is important to with peers. Many children who fit You are certainly not alone. remember that an essential feature into the diagnostic criteria for ODD Every child tests the limits now and of ODD is a recurrent pattern of are often bright, well-liked, coop- again, but it is the children with negativistic, defiant, disobedient erative with teachers and coaches, Oppositional Defiant Disorder and hostile behavior toward author- and are polite to other adults. The (ODD) that push the limits to such ity figures that persist for at least Barbara Greenberg, Ph.D. incongruity of the behavior inside an extent that nearly every conver- six months and is characterized by of the home easily reinforces that sation with him or her ends up be- the frequent occurrence of at least notion that the parents are to blame ing an exhausting power struggle or four of the following behaviors • Being touchy or easily annoyed for their children’s abrasive behav- argument. As such, even the par- which must occur more frequently by others ior towards them and others. There ent’s relationship with one another than is typically observed in indi- are times when the oppositional often becomes stressed as each par- viduals of a comparable age: • Being angry and resentfully behavioral patterns can emerge at ent blames the other for the child’s school and/or social settings, often outrageous behavior. The transient • Loss of Temper • Being spiteful or vindictive suggesting to parents that teachers oppositional behavior typically as- or others are to be blamed for the sociated with early-childhood, ado- • Arguing with Adults It is worthwhile mentioning that problems. lescence, and other developmental very often children and adolescents stages needs to be ruled out before • Active defiance or refusal to with ODD do not see themselves as So, if Parents Aren’t to Blame, pursuing this diagnosis. comply with the request or persistently stubborn, resistant to What Causes ODD? rules of Adults direction, unwilling to do chores or What to Look For tasks or especially argumentative. No one knows for sure. Most • Deliberately doing things that Rather, they justify their own be- experts believe that a child’s inher- Symptoms of ODD usually be- will annoy other people havior as a simple response to un- ent personality and disposition con- come evident before the age of reasonable demands placed upon tribute to the syndrome. Many eight years old but not later than • Blaming others for his or her them, or unreasonable circum- times, early adolescence. Associated fea- own mistakes or misbehavior stances into which they have been see ODD on page 32

Safety First, Interpretations Later: Treatment of the Self-Harming Patient

Private Practice, Hastings-on-Hudson, New York. Author, “When the Body is the Target: Self-Harm, Pain, and Traumatic Attachments.” PAGE 32 A WINTER 2004 ADVERTISING SUPPLEMENT SPONSORED BY FOUR WINDS HOSPITAL ODD from page 31 use to describe it will directly influence the Inflexibility + Inflexibility = Meltdown strategies you use to help your child change however, the symptoms become exacerbated in this behavior. Essentially, the numerous variables that may the home when the parents are not educated as be fueling your child’s difficulties should be to how to handle it. An informal survey of • Putting your old interpretation on the shelf sorted out and evaluated by a mental health mental health professionals said that it is typi- will also mean putting your old parenting professional who will help you to develop a cal for parents with an ODD child to feel iso- practices on the shelf. In other words, help- plan on how to proceed. lated and ineffective. Ross Greene, Ph.D., au- ing your child to be more flexible usually thor of, “The Explosive Child” says, “You means that you will have to be more flexi- Dr. Greenberg is the Program Director of don’t know anything about kids like this until ble first. This isn’t as unfair or unreason- the “Lodge” Adolescent Unit at Four Winds you have one. Until people have walked in able a statement as it may sound, for you’ve Hospital. She can be reached by calling 914- these parents’ shoes, they have no idea.” already experienced the futility of respond- 763-8151 ext. 2482. Along with symptoms inherent to ODD, ing inflexibly to a child who is, by nature, many times there are related problems such as inflexible. I’ve often used a simple equa- Resource: Greene, Ross W., Ph.D. “The hyperactivity, mood disorders, anxiety and con- tion to capture this phenomenon: Explosive Child” New York, Harper Collins. duct disturbances. It is sometimes more effec- tive to treat a child or adolescent with ODD once some symptom relief is obtained through the use of medication for the problems related with this syndrome. “These kids maintain an oppositional atti- tude even when it’s clearly not in their best in- terest,” says Ross Greene, “so we have to as- sume that they would be doing well if they could, but they lack the capacity for flexibility and frustration management that ordinary chil- dren develop.”

Approach it from a Different Angle

In order to establish the diagnosis, parents should seek the help of a mental health care professional who is experienced in diagnosing children and adolescents. Individuals with ODD do not typically respond to the usual “rewards and punishments” systems established by parents and teachers. Rather, they need to be taught methods of coping with their own inability to handle frustration and impulsivity. Parents are best advised to remember that the child needs help dealing with difficult feelings. When your child is able to turn even the most simple conversation or event into a power struggle, you have to try to disengage until the situation calms down. Not easily done! In ad- dition, carefully using humor to defuse an esca- lating situation is often very helpful. This often relives tension and gives the child permission to calm down. Seek assistance. Parents also need support and can benefit from learning some of the current, therapeutic techniques available to them and their child for coping with this disruptive disorder. Dr. Greene suc- cinctly summarizes some thoughts and ideas regarding the inflexible-explosive child in the following paragraphs:

• Flexibility and frustration tolerance are critical developmental skills that some chil- dren fail to develop as they move beyond the terrible twos. Inadequate development of these skills can contribute to a variety of behaviors – sudden outbursts, prolonged tantrums, and physical and verbal aggres- sion, often in response to even the most benign of circumstances – that frequently have a traumatic, adverse impact on these children’s interactions and relationships with parents, teachers, siblings, and peers.

• How you interpret your child’s inflexible- explosive behavior and the language you Mental Health News - New York City Section: Winter 2004 Page 33 The Mental Health News New York City Section

What Does The President’s Commission On Mental Health Have To Do With NYC ?

By Lloyd Sederer, MD when institutional care was the norm between those who provide care for Executive Deputy Commissioner rather than the exception, people with mental and physical disorders. This New York City Department of Health mental illness were left to languish with should be done in at least two ways: in and Mental Hygiene little or no hope for their recovery. To- the care of people who suffer from a day most people with mental illness live mental illness as well as an addiction or independently; many work and enjoy a a developmental disability (such as men- t’s been 25 years since President good quality of life. We have also tal retardation); and between general Carter ordered the creation of the learned how to define, measure and im- medical/primary care services and the last Presidential Commission on prove the quality, safety and dignity of mental health system. If one part of a Mental Health. First Lady Rosalyn mental health services. The work of en- person is treated while another is over- ICarter was at the helm and its report was suring quality must be done locally, looked, treatment falls short and is ex- front-page news in the New York Times. where services are delivered and im- cessively costly, individuals and families When Carter lost a second term, momen- provements can be realized. Achieving suffer, and social institutions including tum was lost and a major piece of legis- effective and humane mental health ser- lation subsequently repealed. A glorious vices can become the defining operating courts, jails and hospitals pay the price. beginning, yet a short lifespan. The directive of city and state agencies. While the Commission highlights these President’s priorities matter. Issues of financing are also critical. problems, it does not propose local solu- In 2002, President George Bush cre- Payment for mental health services must tions, where their reality is deeply felt ated the New Freedom Commission on be fashioned to provide incentives for and where the most hope lies for improv- Mental Health. In July, the Commission good care and we must stop supporting ing care. Cities and states can begin issued its final report. The story ap- poor treatment. When money is spent where the Commission stops short. We peared on page 10 of the New York more judiciously and efficiently more plan to do so. Times: a less than glorious beginning but value derives, which helps in realizing Lloyd Sederer, M.D. In New York City, we will use the with the prospect of reviving a national what the Commission called “budget occasion of this report to support our discussion on an issue too often ne- neutrality” (i.e., no additional money). In efforts to improve the public mental glected, and because of stigma, too often NYC we are committed to abolishing a the needs of people with mental illness. health system. Our approach focuses pushed to the side of the nation’s health decade-long state limit on how many When the mental retardation and devel- foremost on quality mental health care: priorities. Medicaid dollars can be spent for outpa- opmental disabilities community fought recipients of services should be able to There is much to applaud in the Com- tient mental health care. This stems from for an exemption from this exclusion access and receive the best care that ex- mission’s Report. It is optimistic that the continuing refusal to see mental ill- years ago, legislators recognized that ists. City government owes this degree recovery is possible, as is a productive ness as a health condition worthy of the group homes were clinically necessary and proud life. The report encourages a same treatment as other health disorders. as well as economically far-sighted. of value purchasing to its residents. We person and family-centered approach to People who need care for cancer, diabe- Government invested public dollars to are working to undo clinically, morally services and emphasizes the growing tes or any other health ailment are not pay for them. Advocates for people with and economically foolish policies. As a effectiveness of treatments and the similarly cut off from needed care. Until mental illness have not yet had similar merged health and mental health depart- steady advances in mental health sci- the cap is removed, mental health or- success. This exclusion stands in the way ment we are breaking down the artificial ences. Its honesty makes it credible: the ganizations can’t afford to provide ser- of developing homes for people with barriers between medical and mental national system is bluntly described as vices because Medicaid won’t reimburse mental illness, who need community health services that prevent people from fragmented, disconnected and inade- them for doing so. The consequence is living support but instead languish in receiving the coordinated care that we quate; “unmet needs and barriers” are that many people go untreated, creating scandalous adult homes, in shelters, or know works best. And we plan to en- legion. costs in shelters and hospitals. They also on our streets. courage the innovation that can make This does not mean the report is com- end up on public assistance rolls, and in Changes in Medicaid rules, which our system of mental health care even plete. In some key ways, it does not go correctional facilities, creating even now create discriminatory financial bar- more safe and effective. If we do all of far enough. It does not identify, for ex- greater governmental and societal costs. riers to care such as these two men- that, we will have met our obligation to ample, how to get states and cities to Similarly, community-based group tioned, can and have been achieved, im- achieve desired goals. Notably, it over- residences that provide care for 16 peo- proving lives while not costing cities or the people of this City, and in so doing looks how the science of medical quality ple or more also do not receive Medicaid states more money. The report stops offer an example of how to improve care improvement can enhance the care of reimbursement. This is because of a short of urging these reforms. for people with mental illness to other people with mental illness. Years ago, federal law that again does not consider We must also break down the walls communities across this country.

Mental Health News is Now Seeking Articles & Display Ads For These Exciting Upcoming Issues:

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Page 34 Mental Health News - New York City Section: Winter 2004

Children Bereaved by the Suicide Death of a Loved-One

By: Cynthia R. Pfeffer, M.D., Director overwhelming anxiety. It is associated complex event for children and their fami- Interventions may be provided in indi- Childhood Bereavement Program with behaviors of clinging to their parents lies. Intervention in the form of guidance vidual formats or in group formats. Our New York-Presbyterian Hospital and fears that separation from the parent and counseling is often valuable for such experience in the Childhood Bereavement may cause something to happen to their families. Shortly after the death, families Program of Weill Medical College of Cor- parent. Children may exhibit frequent and experience the shock and trauma of the nell University is that many children bene- increased irritability. They may not be death. Parents may be assisted to under- fit from individual intervention because able to sleep alone and want to be with stand their children’s needs regarding in- this provides maximum attention to chil- their bereaved parent. They may report forming their children about the nature of dren’s needs to express their personal ideas bad dreams or nightmares. They may the death, attending funerals, planning for and gain consistent support. Group inter- show regressed behaviors such as bedwet- daily routines for children and managing vention is provided to assist children to ting or talking like a younger child. Such parents’ own grief responses. Most impor- learn how other children cope with the bereaved children may have heightened tant in the early period is to support the death of a loved-one. The approach of the problems concentrating and demonstrate family in coping with the shock of their Childhood Bereavement Program at Weill fidgety behavior. They may complain of loss. Assisting parents to identify other Medical College of Cornell University is to aches and pains, such as stomachaches, supports for themselves and their children work also with the parents of children be- headaches, tiredness, and lack of energy. in the early period after the suicide death is reaved by the suicide death of a loved-one. They may not wish to participate in activi- an important aspect of intervention. This approach addresses the specific needs ties that they usually enjoyed. They often An important characteristic of interven- of the parents to express their grief while are confused about what happened and find tion is creating an atmosphere for children gaining insights about their grieving chil- it difficult to speak with their grieving and their parents to speak about their ex- dren’s needs. parents because they sense that their par- perience and responses to the loss. It is As a compliment to the work of assist- ents are having a difficult time enduring essential to determine if children, who are ing parents to administer to the needs of their own intense grief. bereaved by the suicide death of a loved- their children, The Childhood Bereave- Sometimes children discover the de- one, suffer from psychiatric disorders or ment Program at Weill Medical College of ceased at the scene of the suicide death. impairing symptoms that require special Cornell University offers group meetings This is one of the most profoundly trau- psychiatric intervention. Specifically, it is for parents who lost a child as a result of Cynthia R. Pfeffer, M.D. matic experiences that children can experi- important to identify if acute stress disor- suicide. This group intervention provides ence. Such an occurrence usually causes der or posttraumatic stress disorder are such parents an avenue to focus on their he ultimate outcome of people acute stress reactions or posttraumatic present. Additionally, it is important to specific bereavement needs. It enables suffering from mood disorders, stress disorder. Such reactions are mani- identify if bereaved children suffer from them to explore their questions about what such as major depressive and fest by behavioral and emotional problems. mood or anxiety disorders that also may led to the death of their children, to explore bipolar disorders, and substance These include severe anxiety and efforts to require psychiatric intervention. Chil- their unique family features of bereave- Tabuse, schizophrenia, and certain personal- avoid anything that reminds children about dren’s degree of social impairment result- ment, and to address their relationships ity disorders is suicide. The suicide death what was observed at the scene of the sui- ing from the complex reactions to the sui- with others in the community. The support of a loved-one begins a long process of cide death. Children are disturbed by in- cide death are essential to identify so that from each member of the group strength- searching for answers about why the sui- tense intrusive thoughts about what oc- intervention can be developed to decrease ens parents’ ability to cope with the trauma cide death occurred. People who lost a curred, feeling angry that the death oc- such social distress. of their loss and to develop additional loved-one as a result of suicide are a cohort curred, feeling guilty that they may have Evaluation of children’s grief reactions means of coping with their profoundly of individuals who often are isolated by caused the loved-one to die, and fears that is essential. This involves determining altered lives. their community and have perceptions of other deaths of loved-ones may occur. children’s concepts of longing for the de- being stigmatized. Additionally, the Frequent behaviors displayed by such trau- ceased, sadness and anxiety, guilt about Need to Enlarge the trauma of witnessing the suicidal act or matized bereaved children are heightened causing the death, suicidal ideation related Current Scope of Understanding being exposed to the death scene produces impulsivity and hyper-reactivity, manifest to wishes to join the deceased, and intru-

intense distressing feelings of anxiety that by anxiety in response to sudden unex- sive thoughts that may affect children’s At present, there is sparse objective is often associated with persistent and in- pected noises or events. Aggressive be- participation in usual activities and aca- information about the long-term character- trusive thoughts about what was observed. havior and feelings of self-devaluation are demics. istics of children who suffered the loss of a Being bereaved by suicide of a loved-one expressed by such traumatically bereaved Evaluation of children’s understanding loved-one resulting from suicide. How and is a burdensome personal experience. children. Some children who were exposed of the nature of the death and their degree whether such children’s development is Children who lose a loved-one as a to a suicide death scene may have suicidal of direct exposure to the death scene is different from children who did not have result of suicide suffer from similar con- ideation as an effort to rid themselves of essential. Intervention to decrease trau- this experience is important to determine. cerns as adults. However, children often their painful emotions and problematic matic images of the death and to guide This can be accomplished through system- lack mature capacity to understand the behaviors. These types of symptoms are acquiring objective information about what atic follow-up of such bereaved children. nature of a suicide death. Furthermore, expressions of acute stress disorder or is suicide is essential to preventing suicidal The effects of the severe stress of such loss children’s responses are shaped by their posttraumatic stress disorder. They are behavior of such grieving children. on children’s development require discern- developmental level. Children’s responses often not recognized as manifestations of Evaluation of grieving parents is essen- to the suicide of a loved-one are also de- such psychiatric disorders and, as a result, tial with an aim of understanding their ing. The effects of parental coping with pendent on their bereaved parents’ coping interventions are often delayed or not pro- means of coping with their loss and need bereavement on the development of their styles. vided to such children. for knowledge about their children’s be- grieving children are yet to be understood. Notably, having a parent who is be- Most children who lose a loved-one as a reavement. Evaluation of parental psycho- Efforts to prevent suicide can be de- reaved by the suicide of a loved-one com- result of suicide are not directly exposed to pathology resulting from their witnessing rived by understanding the details of chil- plicates the grieving of children. Impor- a suicide death scene. However, children the suicide or exposure to the suicide scene dren’s experiences subsequent to the sui- tantly, a child who loses a loved-one as may be exposed indirectly because they is essential. Evaluation of parental social cide death of a loved-one. Bereavement result of suicide usually loses their be- hear about the nature of the death from supports is necessary to help parents sup- intervention, with long-term follow-up of reaved parent’s usual degree of attention. others. While it is important for children port their children. Parents have double children bereaved by the suicide of a The quality of the parent-child relationship to have truthful information about how tasks. They must attend to their own loved-one can support healthy develop- is usually markedly altered by the com- their loved-one died, it is essential that grieving. They must also attend to their ment of such children while offering bined parent and child processes of be- telling children about the suicide of a children’s grieving. How parents endure needed insights about how to interrupt the reavement. Children bereaved by suicide loved-one be carried out as a process and this requires evaluation. processes that may lead to suicidal behav- of a loved-one also often lose the solace with sensitivity to children’s developmen- Specific interventions are planned to be ior. from peers and other adults, such as their tal capacities. Parents may benefit from compatible with the issues identified dur- peers’ parents and teachers, because of the professional guidance in their efforts to ing the evaluation of the above issues. For Dr. Pfeffer is a Professor of Psychiatry likelihood of secrecy and stigma often inform their children about the suicide most children, the focus is on providing at Weill Medical College of Cornell Uni- associated with suicide. Thus, the social death of a loved-one. grief intervention. When severe symptoms versity. You may contact Dr. Pfeffer by support so essential for children’s develop- associated with psychiatric disorders are phone at 914-997-5849, or by Email, at ment is often weakened after children ex- The Role of Intervention for Children identified, intervention should address [email protected]. Help is avail- perience the suicide of a loved-one. Bereaved by the Suicide of a Loved-One reducing these symptoms. Similar concepts able at New York-Presbyterian Hospital in How do children react to the suicide of guiding intervention are applied for par- White Plains, and in Manhattan at York a loved-one? A prominent emotion is Suicide of children’s loved-ones is a ents’ concerns. Avenue and East 68 Street. Mental Health News - New York City Section: Winter 2004 Page 35

New York - Presbyterian Psychiatry Page 36 Mental Health News - New York City Section: Winter 2004

Co-Occurring Disorders and Suicide Risk…A Daily Trauma

By Joyce Kevelson, Assistant Vice program, staff are constantly vigilant of President, Behavioral Health Services, suicidal indicators and utilize accepted Dan Schlieben, MSW, and clinical tools to evaluate at-risk clients. Donna Ray, CSW-R The results of these evaluations may FEGS require further clinical assessment and often result in hospitalization. Statisti- cally, nearly half of all psychiatrists and uicide is the 11th most common a third of all mental health professionals cause of death in the United have experienced a suicide among cli- States and 13th worldwide. Re- ents. Unfortunately, ninety percent of S search tells us that individuals people who commit suicide have a psy- with co-occurring mental illness and chiatric disorder and of those, 60 percent substance abuse disorders are clearly have mood disorders - commonly major more at risk for suicide. depression and bipolar disorder. Of par- When Susan first arrived at FEGS/ ticular concern are individuals like Project COPE, a Dual Recov- Susan, whose symptomology often ery program in Jamaica, NY, every day comes in the form of suicidal gestures, was a potential crisis: Susan (not her real perhaps as a way to regulate emotional name) who is diagnosed with Major distress. Additionally, clients who use Depressive Disorder and Cocaine drugs and alcohol have a heightened Abuse, had overdosed on her meds after risk, as do those whose families have hoarding them for a three-month period. experienced suicide or suicide attempts. Through a formal risk assessment proc- "We are always very concerned about ess, using the Addictions Severity Index all of our clients," says Donna Ray, "and (ASI), Susan was assessed at very high we work closely with other providers risk for suicide. Slowly but surely, when we have a sense that a client is Susan came to understand that her suici- particularly vulnerable. We also know dal gestures were a maladaptive form of that programs like Project COPE can act self-punishment, possibly a reaction to as a safety net and teach important life her guilt over abandoning her children. skills and goal setting. Clients focus on Susan began to verbalize her thoughts positive outcomes within their reach, about her family, both at Project COPE particularly in the areas of housing, and with her therapist at her outside learning, socializing, social supports and clinic. "I am no longer using suicidal harm reduction. A sense of hope is often behavior as a way to express myself, but a deterrent to suicidal behavior." I still occasionally have those thoughts." Research suggests that suicidal cli- Susan and other clients with strongly ents must be evaluated for their ability to expressed feelings about suicide, control impulses and take responsibility whether "gestures" or as "manipulation," for their lives. Clients also need to be are encouraged to participate in Dialecti- counseled to use "hot lines" and cal Behavior Therapy (DBT) offered at "buddies" and to talk about suicidal feel- Project COPE. " Getting into the habit ings whenever they are experienced. of using DBT skills was hard at first but While such a revelation can be unset- once I did they were helpful," she says. tling, even for those well trained in men- On other days, Susan attended Dual Re- tal health, clients need to feel they will covery and Skill Building groups, all find support from all sources, including aimed at assisting her with developing families and friends. insight as well as learning functional Dialectical Behavioral Therapy skills to use on days when she is not (DBT), developed by Dr. Marsha Line- attending the program. han, of the University of Washington, is Susan participates in a unique pro- particularly useful for persons with per- gram of dual recovery at Project sonality disorders. Many therapists use COPE, which allows clients with severe this form of therapy to aid patients with emotional problems or mental illness to new modes of thinking and to find better attend even while they may be strug- and more positive solutions. While such gling to recover from active drug therapies are evidence-based, providing use. Using a harm reduction approach this modality of treatment for persons with clients who are still struggling to who are thought disordered is perhaps achieve their goal of abstinence from one of the most difficult challenges fac- drugs, has proven helpful. We have ing mental health and rehabilitation pro- found that this strategy helps clients fessionals, including the staff at Project gradually achieve their goal. COPE. "Building such a program for clients "Of all the challenges we face with like Susan and others has been a real dually diagnosed individuals who come challenge," says Program Manager through our doors, the risk of suicide is Donna Ray, who along with F.E.G.S the most challenging. We train staff to Assistant Vice President Joyce Kevelson be vigilant for clients' suicidal indica- has championed Project COPE for the tions and to monitor them closely," says three years of its existence. The program Donna Ray. "We are also dealing with occupies a bright, cheerful suite of social stigma which makes suicide and rooms in a building on 161st Street in talk about suicide, especially among Jamaica, NY. clients and even some staff, very While Project COPE counts itself fortunate not to have had a suicide in the see Co-Occurring on page 55 Mental Health News - New York City Section: Winter 2004 Page 37 The Coalition Report

Checking in on Our Democratic Presidential Candidates:

Where do they Stand on Mental Health ?

By Michael J. Polenberg need for “health care reform” in one readers how the candidates choose to where the General stands on mental Coalition of Voluntary manner or another, it is less apparent publicly underscore their positions on health policy issues. Perhaps owing to Mental Health Agencies how each one would address the need for mental health policy. the fact that he entered the race much mental health care reform. As the campaign progresses over the later than his opponents, General Clark’s With this in mind, the Coalition of course of the year, and additional candi- campaign did not have any information Voluntary Mental Health Agencies ex- dates enter or withdraw from the race, to share with our readers by the time this amined the positions of the nine current this publication will update its readers on issue went to press. Democratic Presidential candidates in the status of mental health issues in the Howard Dean order to gain a deeper understanding of campaign. www.deanforamerica.com what they’ve accomplished in the field In the interests of impartiality, the of mental health reform and where they candidates are listed in alphabetical or- Governor Dean includes both “A Re- would direct their resources should they der. cord of Accomplishment on Mental win the Presidency. Health” and a “Mental Health Reform Carol Moseley Braun Agenda” on his campaign website. We found that only a few of the can- www.carolforpresident.com didates specifically address mental Among Governor Dean’s accomplish- health issues on their campaign websites, Ambassador Braun calls for a single- ments during his tenure (1991-2003) was which is unfortunate given the increased payer health care plan that would allow his enactment of insurance parity legisla- reliance by voters on the Internet for every American to obtain insurance tion in 1997. This legislation requires pertinent information. Inasmuch as they through the government. She also be- insurance companies in the State to pro- Michael J. Polenberg have not already done so, we believe it is lieves that doctors and nurses should be vide equal benefits to persons suffering extremely important that each of the able to recommend a course of treatment from psychiatric disabilities as they do candidates dedicate a portion of their regardless of what the insurance compa- for physical disabilities. s the country moves closer campaign websites to mental health pol- nies would pay for. Ambassador Braun According to his campaign office, and closer to the 2004 elec- icy in order to allow consumers and their does not make any specific reference to Governor Dean promises to enact parity tions, it is worth spending a families, providers, advocates and other mental health policy on her website. legislation on a national level should he win election to the Presidency. In addi- few minutes examining the interested parties to more critically ex- Wesley Clark A tion, he lists six other areas of mental positions on mental health policy articu- amine each candidate’s commitment to www.clarke04.com lated by the current crop of candidates these important issues. health policy in which he would enact seeking the Democratic nomination for The following summary of the candi- Neither General Clark’s campaign reform, including the use of treatment President. While many of us have heard date’s positions is by no means exhaus- office nor his campaign website were rather than the candidates speak about the general tive. Rather, it is intended to show our able to provide any information on see Candidates on page 40 Page 38 Mental Health News - New York City Section: Winter 2004

Early Detection and Intervention Offers a Lifeline to Help Thwart Suicide

By Giselle Stolper, Executive Director and behaviors to look out for among DOHMH utilize active public education Our screenings for depression take Mental Health Association friends and relatives. Launched in 1996 in campaigns, targeted at specific audiences – place at senior centers and schools of New York City partnership with the Department of Health seniors and adolescents, for instance – to throughout the city, including in Latino and Mental Hygiene, 1-800-LIFENET was increase awareness of mental illness and and Asian communities. The screening day created to assist persons seeking help for remind people there are life-affirming al- includes offering discussion and a brief emotional, drug or alcohol problems by ternatives when they begin to believe sui- questionnaire that the participants com- assessing their needs over the phone and cide is a viable option. In the past seven plete and then review in one-on-one meet- linking them to the appropriate treatment years LifeNet and DOHMH have con- ings. and support services. Callers may be in ducted nearly a dozen campaigns through- During a presentation, COPE staff dis- crisis, or they may be experiencing ongo- out the City. Examples of posters from cuss symptoms of depression so the par- ing problems in living. LifeNet is an infor- these campaigns are featured on the next ticipants can identify signs in themselves mation source for people who are con- page. and among their friends, and they circulate cerned for themselves or their loved ones, Several measurements indicate the hot- the LifeNet phone number – though sen- and also gives people feeling hopeless and line is doing its job of building awareness iors and youth are less likely to make a helpless a place to call, 24/7, before they and providing a resource for those at risk phone call in this instance. However, face- turn to suicide. and those who want to help another. to-face, seniors are eager to discuss their 1-800-LIFENET offers two advantages LifeNet call volume grew from just under issues and feelings, quite a departure from for the troubled caller. First, the hotline has 1,000 calls per month in 1996 to 3,000 the stoicism or skepticism many would authorized linkages with the City’s crisis calls per month in 2001. Since the events expect to find within the age group. For and emergency services, including Emer- of September 11th, call volume has doubled youth, MHA of NYC’s COPE staff works gency Medical Services and the City’s 25 to average 6,000 calls per month. closely with school faculty and parents to psychiatric mobile outreach teams. When Beyond sheer volume, the content of we receive an emergency call (defined by calls has changed. At the time of LifeNet’s ensure that children and teenagers identi- 911 and EMS as a situation in which some- founding in 1996, one in 35 calls to the 1- fied as “at risk” get the help they need. Giselle Stolper one can be a danger to him/herself or oth- 800-LIFENET hotline constituted an emer- COPE staff also offers training pro- ers within the next 24 hours) we can patch gency. Today, approximately one in 120 grams on grief and loss and stress manage- the call into 911 for immediate action. callers reports such an emergency. That ment. We have worked with the Depart- Second, our hotline is staffed by mental favorable change in ratio indicates callers ment for the Aging’s Partner to Partner here are few words you can im- health professionals, most with masters- utilize the hotline more for information and program, a group of peer educators. COPE part to grieving families that will level degrees, who can assess the caller’s referral – before their problem reaches professionals trained these advocates to alleviate their pain after the sui- risk for causing harm and act quickly. In crisis stages – using their awareness of identify the symptoms of depression T cide of a loved one. The guilt that non-emergencies, LifeNet’s referral spe- LifeNet to reach out when the issue at hand among their peers. We have also conducted they could have done something to stop it, cialists maintain the City’s largest database is challenging but not life-threatening. This screenings with the Department of Aging’s the rage and bewilderment at the senseless- of support and treatment resources, allow- is a trend we plan to continue. grandparent resource centers and support ness of the act, and the sheer loss, cause ing them to find the most suitable options groups for grandparents raising grandchil- enormous anguish to those left behind. to meet the caller’s individual needs. Early Detection dren. Survivors cannot comprehend how their LifeNet also operates a hotline for Spanish for Suicide Prevention For COPE staff, informing seniors, relative or friend, no matter how troubled, speakers, 1-877-AYUDESE and Asian youth, family members, school faculty and evolved from feeling upset, to feeling des- LifeNet, 1-877-990-8585. We use a trans- Suicide rates among people with emo- caregivers about 1-800-LIFENET is cen- perate, to thinking about suicide, to actu- lation service for other languages. tional disorders is disproportionately high, tral to their overall outreach efforts, so ally committing suicide, all without others Most callers seek information and refer- especially for depression, bipolar disorder, persons can know that there is a place to catching on and intervening before it was ral services to help them address a mental and anxiety-related disorders. This is access help at any time, on any day, when- too late. They rehash conversations and health issue and one-third of our calls are where early detection can prove critical in ever it is needed. interactions, scrambling for some clue of from case workers, friends or family who suicide prevention. The MHA of NYC is We cannot overemphasize the impor- the suicide’s state of mind, looking for the are calling on behalf of a client, friend or one of the area’s leaders in providing men- tance of the community in our efforts to juncture at which someone could have relative. Whether the call is from the indi- tal health screenings through our Commu- stepped in and literally, stopped the mad- vidual or someone calling for another, nity Outreach and Public Education prevent suicide. One of our primary mis- ness. LifeNet specialists probe to tease out at- (COPE) campaign. sions is to help friends, family members There is no way to end suicide once and risk behaviors and thoughts, all of which In the last issue of Mental Health News and other professionals to better recognize for all. Yet as mental health professionals, can indicate a suicide in the making. For we described COPE’s depression screening mental health problems among the persons if we can identify individuals who are at instance, we determine whether the indi- program for the junior high and high they know and care for, so persons feeling risk of committing suicide, and if we can vidual potentially at risk has a history of school level, to identify students most at alone with their suffering can be directed help them seek even a brief respite be- self-injury, whether he or she has access to risk for depression and to help them access to receive the help they need. The 1-800- tween when they begin thinking about a means for committing suicide (a gun, a treatment quickly. The National Institute of LIFENET hotline offers a caring, profes- killing themselves and when they might bottle of pills, etc.), how frequently he or Mental Health (NIMH) cites that among sional ear to anyone who may want to actually do it, we can help save lives. she has talked or thought about suicide, teens and college-age students, suicide is reach out but doesn’t know whom to call, At the Mental Health Association of and how concrete plans may be (if the per- the third most common cause of death after and depression screening can help identify New York City, we work toward early son has considered a date or a method, for accidents and homicide. those who are at risk. If you are interested detection and appropriate intervention to example). Just as important, our profes- COPE also conducts active mental in hosting a depression screening program help prevent suicide through our crisis and sionals ask if the individual had someone health screening, primarily for depression, for your group or organization please con- information and referral hotline, 1-800- close to him or her who actually commit- among senior citizens. It may be surpris- tact Dr. Rachelle Kammer, Director of the LIFENET, and through our depression ted suicide, because it sets a precedent that ing, but seniors comprise the highest at- COPE campaign, at the Mental Health screening programs. can seem like a go-ahead to someone risk population in the United States. NIMH Association of New York City at 212-614- struggling with suicidal thoughts. notes that Americans over 65 make up 13 6300. 1-800-LIFENET LifeNet conducts continual outreach to percent of the population, yet in 2000, Dr. John Draper, Director of Public Awareness that Leads to Intervention circulate the hotline number and ensure accounted for 18 percent of the nearly Education and the LifeNet Multicultural

people struggling with emotional difficulty 30,000 suicides committed that year. Hotline and Dr. Rachelle Kammer contrib- One key to assisting in suicide preven- have the number on hand when times get White males aged 85 and over comprised uted to this article. tion is to raise awareness of the symptoms tough. In addition, LifeNet and the the largest group within that category. Mental Health News - New York City Section: Winter 2004 Page 39

Mental Health News Metro-New York Leadership Committee

Peter Campanelli, President & Chief Executive Officer Evelyn J. Nieves, Ph.D., Executive Director Institute For Community Living Fordham-Tremont Community Mental Health Center

Amy Chalfy, Mental Health Director - Bronx District Evelyn Roberts, Ph.D., Executive Director JASA NAMI - New York City Metro

Kenneth J. Dudek, Executive Director Phillip Saperia, Executive Director Fountain House Coalition of Voluntary Mental Health Agencies

Mary Guardino, Founder & Executive Director Alan B. Siskind, Ph.D., Executive Vice President & CEO Freedom From Fear Jewish Board of Family & Children’s Services

Mark D. Gustin, M.B.A., Senior Associate Director Giselle Stolper, Executive Director Kings County Hospital Center Mental Health Association of New York City

Mary Hanrahan, Director, Treatment Services Jonas Waizer, Ph.D., Chief Operating Officer New York Presbyterian Hospital - Payne Whitney Division F.E.G.S. Behavioral & Health Related Services

Rhona Hetsrony, Executive Director Joyce Wale, Assistant Vice President - Behavioral Health North Shore LIJ Health System - Zucker Hillside Hospital New York City Health & Hospitals Corporation

Joseph Lazar, Director, New York City Field Office Peter Yee, Assistant Executive Director New York State Office of Mental Health Hamilton - Madison House

Margaret E. Moran, C.S.W., VP of Admin Services Behavioral Health Svcs. - St. Vincent’s Catholic Medical Centers committee in formation Page 40 Mental Health News - New York City Section: Winter 2004 Candidates from page 37 Senator Kerry is a member of Con- gress’ Health Care Subcommittee, and incarceration for mentally ill offenders, has introduced several pieces of legisla- funding peer support and counseling, tion to provide assistance to Americans Suicide and Older White Men and adequately funding employment living with psychiatric disabilities. programs for mentally ill Americans to Senator Kerry co-authored the allow them to shift from public to pri- “Medicare Mental Illness Nondiscrimi- vate health insurance. nation Act” and the “Medicare Mental Governor Dean would also seek to Health Co-payment Equity Act”, both of invest in programs that integrate mental which seek to lower the cost for mental health care with substance abuse treat- health treatment for Medicare recipients. ment, specialized housing, and other Senator Kerry’s Statement on Mental social services; fund specialized pro- Health Policy calls for parity in both grams that identify and assist children public and private insurance programs. with psychiatric disabilities; and pro- He would allocate resources to commu- mote community-based care as a more nity-based mental health care to target cost-effective manner in which to pro- underserved populations such as women vide treatment. and minorities, and would work towards de-stigmatizing mental illness in order to John Edwards encourage more Americans to seek treat- www.johnedwards2004.com ment and counseling.

Senator Edwards campaign platform Dennis Kucinich includes a plan to increase insurance www.kucinich.us coverage, reduce disparities in health By Benjamin R. Sher, MA, CSW Even economics play a part in suicide care, and add 100,000 nurses over five Representative Kucinich’s campaign Director of Training risk. It has been found that older white years. His plan would offer health in- emphasizes his support for disability and Staff Development male professionals are at risk for suicide. surance to every child in America, and rights, including his pledge to fund com- Institute for Community Living, Inc. Though not fully clear, the reasons for millions of adults. While in the Senate, munity-based care and his support for this risk may be linked to concern for Mr. Edwards introduced legislation that mental health parity in insurance cover- loss of productivity as one gets older or would reduce the cost of medication by age. A campaign spokesman noted the th uicide ranks between the 8 and worry that one cannot “measure up” to $60 million over 10 years. Mr. Edwards candidate’s co-sponsorship of H.R. 676, th 11 leading cause of death in one’s former self. Some of America’s also sought to provide critical mental which includes mandatory parity in the United States. Three factors highest paying professions (e.g. medi- health and substance abuse services to health care coverage. Representative have been identified for risk of cine) have a higher than average statistic women who are victims of domestic Kucinich would also nominate judges S suicide; race, gender, and age. Statistics of suicide. violence or sexual assault (Women in who expressed their support for the indicate that while women attempt sui- Trauma Act, 2002). More recently, Americans with Disabilities Act to en- Interventions cide more often than men, men are four Senator Edwards announced a $20 mil- sure that all Americans are treated fairly. times as likely to complete suicide. In Assessment for clinical depression in lion initiative that would help disabled The candidate would also look for a Healthy People 2000, the rate of suicide older white men is the primary means to Americans find work (“Breaking Down Congress that would enact meaningful for white males aged 65 is noted as 34.1 promote suicide prevention. Studies suicides/100,000 people. For white men Barriers” Initiative). health care reform. have shown that numerous men had con- 85 and older, this rate increases to 100+ Senator Edward’s campaign also tact with their primary care physician in suicides/100,000 people. Suicide and outlines his plan for a Clinic Preserva- Joseph Lieberman the months before ending their life. A tion and Improvement Program (CPIP), www.joe2004.com older white men in America is a national health concern. full mental status completed by a physi- which would greatly increase funding cian may help to reduce risk. for public health clinics. In addition to Senator Lieberman’s campaign notes Risk Factors Knowing the warning signs and risk extending hours and re-locating clinics the economic impact of untreated mental Individuals experiencing clinical de- factors will also help. An older white to more accessible areas, the CPIP illness on the business community in male who loses his wife of many years would promote preventive and educa- terms of lost productivity, and that re- pression are at risk for suicide, as well as other mood disorders such as dysthimia should be supported and connected to as tional measures that target mental illness ductions in care to mental health pro- and manic-depression. Often, these dis- many social outlets as possible. In- and substance abuse, among other ill- grams inevitably shift the cost to prisons orders go undiagnosed in older white creased alcohol use or abuse of pre- nesses. and jails. Senator Lieberman received men. Alcohol or substance use may scribed medication may be a warning an “A” from the National Alliance for mask the symptoms of depression, or the sign. Thoughts about taking one’s life, Richard Gephardt the Mentally Ill (NAMI) in 1998, and in problems of depression are linked to a or open statements about “ending it all” www.dickgephardt2004.com 2000 was named one of NAMI’s Legis- health concern that is the primary focus should be taken seriously, and asking a lators of the Year for his efforts to im- of the physician treating older white person if they have plans to kill them- Representative Gephardt’s campaign prove conditions in hospitals and mental men. Treatment of a chronic medical selves is critical. There is often a fear includes a plan to offer health coverage health institutions, particularly regarding condition such as cardiac problems, dia- that openly asking about suicide will to 97% of uninsured Americans. One of the use of restraints. betes, hypertension, or Alzheimer’s may promote it – this is a myth. More often Representative Gephardt’s accomplish- If elected President, Senator Lieber- promote depression. Many of the medi- than not, people who attempt suicide ments during his tenure in Congress has man would pass legislation that would cations prescribed for treatment may have been thinking about it long before been the "Ticket to Work and Work In- require mental health and substance cause depression as a side effect. someone asks them about it. Other risk centives Improvement Act” (1999), abuse parity for public and employer- Social factors may also promote risk. factors include isolation, marked which allows Americans with disabili- based insurance plans in order to more The developmental milestone for older changes in behavior, giving away life- ties to qualify for Medicaid and Medi- effectively treat Americans suffering persons is an ability to focus on genera- long possessions, or purchasing firearms tivity or end up in despair. Older people care without having to give up their em- from these afflictions. Senator Lieber- or weapons. who feel a sense of accomplishment in ployment. Representative Gephardt was man will also work towards ending ra- Suicide and older white men is a na- their life, have connections to people, also a co-sponsor of the Americans with cial disparities in health care. tional health problem. Given the vulner- Disabilities Act of 1990. are active, and experience pride in their Al Sharpton ability of this population for completed successes are less at risk for depression www.al2004.org suicides, it is crucial that medical and John Kerry than older persons who feel their lives have served no purpose. This is also the mental health professionals collaborate www.johnkerry.com Reverend Sharpton’s campaign ad- to determine and assess risk. Early in- vocates amending the Constitution to time of loss in life. Older persons who lose a spouse or loved one and cannot tervention and proactive measures are Senator Kerry includes a Statement add the right to health care for all adequately grieve may believe living certainly ways to address this problem. on Mental Health Policy on his cam- Americans. Unfortunately, his cam- serves no purpose and a wish to be with The earlier that depression is identified paign website, and his campaign office paign did not provide more specific de- one who died. This appears particularly in older white men, the better it can be provided a record of accomplishment in tails, particularly concerning mental true for older white men, who may not treated. As in all other mental health this area during his tenure in the U.S. health policy, by the time this issue went have been well socialized to express concerns, treatment for suicide preven- Senate. to press. their loss and grief. tion works. Mental Health News - New York City Section: Winter 2004 Page 41

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AAS from page 24 • We can refuse to any longer tolerate a society that does not care enough What can we all do to help? to do all possible to help people lead more well-functioning lives. • We can advocate for better funding; • We can get involved and join with we can donate monies ourselves to others who are actively working to further suicide prevention efforts, prevent unnecessary deaths by sui- education and training, and research cide! studies. • We can become actively involved in For more information visit the AAS state and community coalitions website: www.suicidology.org. formed and forming to promote suicide prevention efforts. Sources: • We can better observe our children, - American Association of Suicidology our elders, our peers, and our loved www.suicidology.org ones; and when we notice anything of concern, we can ask directly - Goldsmith, S. K., Pellmar, T. C., whether suicide thoughts are pre- Kleinman, A. M., & Bunney, W. E. sent. No one kills themselves be- (Eds.) (2002). Reducing suicide: A na- cause they were asked about sui- tional imperative. Washington, D. C.: cide; people die because no one National Academies Press. cared to ask. • We can do everything possible to - Maris, R. W., Berman, A. L., & help those we care about to receive Silverman, M. M. (2000). Comprehen- competently delivered treatment sive textbook of suicidology. NY: Guil- and to comply with caregivers’ rec- ford Press. ommendations. • We can safely store our firearms - National Strategy for Suicide Preven- and, even better, remove their im- tion: Goals and Objectives for Action mediate access to family members www.mentalhealth.org/publications/ allpubs/sma01-3517/ AFSP at-risk. College Film Completed

Pilot-testing to begin in Early 2004

The American Foundation The film’s priority messages: for Suicide Prevention • Depression is a common problem that interferes with students’ ability he Foundation’s short-length both to enjoy college and be produc- film about depression and tive in their work. Depression can or suicide for the college-age will affect you or someone you know. When you need help, Westchester Jewish Community Services is here for you audience has been com- T • Depression is a real illness and is pleted and will be pilot-tested during the upcoming spring semester before not a sign of some character weakness. WJCS offers comprehensive mental health services being distributed to colleges and uni- • Depression is especially danger- versities nationwide. The primary goal of the film, titled ous when accompanied by: severe in- The Truth About Suicide: Real Stories somnia, anxiety, hopelessness, des- Out-patient treatment for people of all ages of Depression in College, is to present peration, feelings of being out of con- Specialized services for individuals trol, and excessive use of drugs and a realistic and recognizable picture of with developmental disabilities depression in college-age youth while alcohol. encouraging those suffering from de- Intensive community–based services pression and other psychiatric disor- • Depression can lead to suicide. ders to seek treatment or to help a for children & their families friend seek treatment. • Warning signs of suicide include Learning Center for children and adults Filming took place at colleges and changes in mood and behavior which universities in the Atlanta, Boston and can be sudden or gradual. Geriatric Care Portland, Ore. areas, with additional footage shot in New York City. Ant • Treatment works and it’s smart to Continuing Day Treatment seek treatment before things get out of Hill Marketing, who is producing the Mobile clinical services film, edited over 40 hours of raw inter- hand.

view footage to create the 25-minute Case management film. • Identify resources and available The AFSP college film is part of a treatment options. Social Clubs growing initiative to help the 18-to-24 • If students are depressed they demographic to recognize depression COMPEER should seek professional help; if their as a serious mental illness; an illness friends are depressed they should sup- All services are offered on a non-sectarian basis that if left untreated, can lead to sui- port them in seeking help. cide. Recent studies have shown that one For more information about the in 10 U.S. college students have seri- AFSP college film, call 1-888-333- Call WJCS at 914-761-0600 ously considered taking their own life. AFSP, or visit www.afsp.org. Mental Health News - Fairfield County Section: winter 2004 Page 43 Mental Health News Fairfield County Section Greenwich Danbury BRIDGEPORT Stamford Ridgefield Norwalk

Courage To Speak: Addressing Drug Prevention

Staff Writer of her son’s death a secret. “I woke the programs and support they need Mental Health News Larry and told him that there was no throughout their school years to maintain way I could get through the funeral. their commitment to reject drugs.” Knowing the truth and not wanting to To provide this ongoing support and at Vigilio’s 7th grade health reveal it was holding me back. Larry mentoring The Courage To Speak re- class at the Ponus Ridge Middle held me and as we talked, a new idea cently developed its "Drug Prevention School in Norwalk, CT, was in came to me, more of a revelation really Curriculum for Middle Schools” with the the middle of the fourth activity than an idea. I said to him, ‘I want to invaluable help of local educators and Pin the new Courage To Speak Drug Pre- speak out. We can prevent other fami- social service providers in Norwalk, and vention Curriculum for Middle Schools. lies from suffering what we have suf- the support of community philanthropic Piloted earlier this year, the program is fered by telling them what happened to organizations like the Fairfield County now being implemented in six Norwalk Ian—if we tell them the truth.’ ‘Yes,’ he Community Foundation and Norwalk middle school health programs and an- said. ‘That's what we'll do.’ " and Wilton chapter of the United Way. other in Bridgeport. The students had The Katzes then embarked on a crash Successfully piloted last January, the just completed presenting their first course to educate themselves about drug 18-hour program begins with Ms. Katz’ drafts of posters containing their own use and prevention and started their or- presentation and is followed by eleven drug prevention messages to the rest of ganization in 1997. Since then, they teacher-led in-class activities and a spe- the class. have given nearly 400 presentations cial presentation designed for parents. If The Curriculum was developed by Ginger Katz reaching over 100,000 children and par- students reveal a need for professional The Courage To Speak Foundation, a ents in Connecticut, New York help or teachers detect it, their principals Connecticut nonprofit founded by Vir- Courage To Speak whose mission rec- (including Westchester), New Hamp- refer them to local service providers with ginia “Ginger” Katz and her husband ognizes the insidious role of silence and shire, Maine, New Jersey, Pennsylvania, whom The Courage To Speak has close Larry Katz. Its mission is to save lives denial in drug and alcohol addiction. Massachusetts, Nevada, Indiana, and working relationships who follow up and by inspiring youth to be drug free “I could not sleep the night before California. She has been invited to provide the students and their families through fostering open education and Ian's burial for thinking about what I speak at state, regional, and national with appropriate support. discussion. The Katzes are the mother would say to the hundreds of people who conferences on prevention and The At the core of this program is the and stepfather of a 20-year-old son, Ian would be at the service.” Like many Courage To Speak has been highlighted personal story of an intelligent and popu- Eaccarino, who tragically succumbed to whose loved ones are victims of sub- on the websites of major prevention or- lar boy who seemed to have everything a heroin overdose in late 1996. Several stance abuse, Ms. Katz felt both internal ganizations like the Partnership for a yet still made the wrong choices. The months later, the Katzes created The and external pressure to keep the cause Drug Free America and the Center for students’ compassion for him and his Substance Abuse Prevention (CSAP) family are a constant motivating force and the Substance Abuse and Mental for their committed participation. Health Services Administration One indication of the effectiveness of (SAMHSA), U.S. Department of Health the program is that after some very ef- Mental Health News Fairfield County Leadership Committee and Human Services. In recognition of fective student letters to the editor ap- David Brizer, MD, Chairman & Medical Editor her organization’s efforts, Connecticut’s peared in Norwalk newspapers saying Governor John Rowland has designated that the Courage To Speak curriculum Committee Members October 3 as “Courage To Speak Day.” should be in every school, educators and

Recent studies indicate that most parents asked Ms. Katz to adapt it for

OmiSade Ali, MA, Director Consumer Affairs William J. Hass PhD, Executive Vice President school-based prevention programs fail high schools and elementary schools. Southwest Connecticut Mental Health System Family Services Woodfield because of the lack of ongoing follow- This process will begin in November.

Alan D. Barry PhD, Administrative Director Lynn Frederick Hawley, MA, Executive Director up. Ms. Katz said, “My experience tells “To say it in one sentence,” says Ms. Norwalk Hospital Department of Psychiatry Southwest Regional Mental Health Board me that there is a second reason for this Katz, “we are reaching into our kids’ failure. Providing information about hearts with our story and then feeding Alexander J. Berardi, LCSW, Executive Director Florence R. Kraut, LCSW, President & CEO KEYSTONE Family & Children's Agency drug use and its consequences is just not their minds—with the help of the Cur- enough. We have to prepare the ground riculum and their teachers—with the Selma Buchsbaum, Member Remi G. Kyek, Director Residential Services Southwest Regional Mental Health Board Mental Health Association of Connecticut first by reaching kids directly and per- information and tools they need to sonally so we can earn their trust and change their lives and help their commu- Douglas Bunnell, PhD, Director Charles Morgan, MD, Chairman commitment.” She accomplishes this by nities fight drugs.” The Renfrew Center of Connecticut Bridgeport Hospital Department of Psychiatry combining her intensely personal story Back in the classroom, Vigilio asked Joseph A. Deltito MD, Clinical Prof. Psychiatry James M. Pisciotta, ACSW, CEO of a family shattered by drugs with the his seventh graders, “How long do you & Behavioral Science, NY Medical College Southwest Connecticut Mental Health System latest information and statistics on sub- think it took you to present your preven- Steve Dougherty, Executive Director Selby P. Ruggiero, LCSW, Associate Director stance abuse and prevention. Ms. Katz tion message?” They agreed it took Laurel House Clinical Services, New Learning Therapy Center speaks with a quiet intensity and rigor- about a minute and half. His next ques- Richard J. Frances MD, Medical Director Marcie Schneider, MD, Director ous emotional integrity that encourages tion, “Do you think if Ian had been able Silver Hill Hospital Greenwich Hospital Adolescent Medicine her young listeners to trust her and the to do that he would have started using Stephen P. Fahey, President & CEO Janet Z. Segal, CSW, Chief Operating Officer advice, information, and statistics that drugs?” elicited a sober round of no’s Hall-Brooke Behavioral Health Services Four Winds Hospital she and Mr. Katz offer. from his class whose imaginative and Susan Fredrick Thomas E. Smith, MD, Medical Director “Hundreds of kids speak to me after well-articulated posters will be displayed Family Advocate Hall-Brooke Hospital our presentations,” said Ms. Katz, “or for the entire school and their parents to

Carla Gisolfi, Director Edward Spauster, PhD. President & CEO send us e-mails expressing their compas- learn from. Dr. R. E. Appleby School Based Health Centers LMG Programs sion and their intention to resist using

Margot O’Hara Hampson, APRN, Manager Wilfredo Torres, MSW, Site Director drugs and alcohol. But that’s not To find out more about The Courage Greenwich Hospital Outpatient Center F.S. DuBois Center enough. Then we—schools, families To Speak and its programs log on to and the community—have to give them www.couragetospeak.org.

Page 44 Mental Health News - Fairfield County Section: Winter 2004

American Association of Suicidology

Hall-Brooke President YOUTH SUICIDE FACT SHEET

• Suicide ranks as the third leading cause of death for young people (ages Urges Focus on 15-19 and 20-29); only accidents and homicides occur more frequently. • Each year, there are approximately 12 suicides for every 100,000 adolescents. Children’s Mental Health • Approximately 12 young people between the ages of 15-24 die every day by suicide. • Within every 2 hours and 2.5 minutes, a person under the age of 25 completes suicide. By Stephen P. Fahey, there are no success stories, or that some President and Chief Executive Officer foster parent’s aren’t loving and caring • In 2000, 29,350 people completed suicide. 13.6% of all suicides were Hall-Brooke Behavioral Health Services people. committed by persons under the age of 25. So the record of protecting and pre- • Whereas suicides account for 1.2% of all deaths in the U.S. annually, they paring our children to run our nation is comprise 12.8% of all deaths among 15-24 year olds. very mixed. There are many successes: wonderful stories of kids who win sci- • Suicide rates, for 15-24 year olds, are 300% higher than those of the 1950’s, ence competitions, youthful musical and remained largely stable at these higher levels between the late 1970’s and the mid 1990’s. wonders, inspirational student leaders, and high school athletes who are role • Suicide rates for those 15-19 years old increased 11% between 1980 and models. But, there are too many dark 1997. Suicide rates for those between the ages of 10-14, however, stories. And continually being ignored increased 99% between 1980 and 1997. Both age groups have shown is the ‘elephant in the room’: the impor- small declines in rates in the past two years. tance of mental and behavioral health of • Firearms remain the most commonly used suicide method among youth, children and adolescents. regardless of race or gender, nearly accounting for almost three of five We read that a child who takes his completed suicides. own life, “was a model student.” We • Research has shown that the access to and the availability of firearms is a hear youthful shooters described as “loners, subjects of hazing.” In both significant factor in the increase of youth suicide. • The male to female ratio (in 2000) of completed suicides was 3.7: 1 among cases, parents, teachers, friends and oth- 10-14 year olds, and 5: 1 among 15-19 year olds, and 6.2: 1 among 20-24 ers in a child’s circle of life, were blind year olds. to, or ignored symptoms of mental ill- ness and the lack of behavioral health. • Black male youth (ages 10-14) have shown the largest increase in suicide And there were symptoms. In some rates since 1980 compared to other youth groups by sex and ethnicity, cases, adults have allowed toxic envi- increasing 180%. Among 15-19 year old black males, rates (since 1980) ronments to develop and prevail, where have increased 80% (2000 data). Stephen P. Fahey hazing is considered “part of growing • Research has shown that most adolescent suicides occur in the afternoon or up,” and is dismissed as a “kids will be early evening and in the teen’s home. kids” fact of life. We’ve averted our • Although rates vary somewhat by geographic location, within a typical high o one can disagree that our eyes to conditions which can have seri- school classroom, it is likely that three students (one boy and two girls) have society’s future is in the ous and negative effects on behavioral made a suicide attempt in the past year. hands of our children. That development. • Nationwide, nearly one in five high school students have stated on self-report N knowledge effects many po- Many children who need psychiatric surveys that they have seriously considered attempting suicide during the litical stances, from President Bush’s or behavioral help don’t get it because of preceding 12 months. education support slogan, “Let no child the stigma they and/or their parents feel be left behind,” to Senator Hillary Clin- is attached to treatment. Others go un- • A prior suicide attempt is an important risk factor for an eventual completion. ton’s child nurturing philosophies in her treated because the adults in their life • The typical profile of an adolescent nonfatal suicide attempter is a female book, “It Takes a Village to Raise a simply fail to recognize certain behav- who ingests pills; while the profile of the typical completer suicide is a male Child.” iors as symptoms. A child seen as who dies from a gunshot wound. In our area of Connecticut, the pre- “bad,” troublesome, or hard to manage, • Not all adolescent attempters may admit their intent. Therefore, any dominant stories in local newspapers may really be a very sick child. Often, deliberate self-harming behaviors should be considered serious and in seem to indicate a powerful interest in that child can be successfully treated. A need of further evaluation. the well being of our youngsters. De- moody child, may be simply that, or • Most adolescent suicide attempts are precipitated by interpersonal conflicts. bates continue over partial versus full may be in a state of clinical depression. The intent of the behavior appears to be to effect change in the behaviors or day pre-school, over the educational Help is available, not just for treatment, attitudes of others. impact of alleged “sleep deprivation,” but for the determination of whether, or caused by opening bells some parents not, treatment is needed. • Repeat attempters (those making more than one nonlethal attempt) use their deem too early. We read of concern Hall-Brooke has a special concern for behavior as a means of coping with stress and tend to exhibit more chronic symptomology, poorer coping histories, and a higher presence of suicidal and over school lunch quality and play- children and adolescents and provides substance abusive behaviors in their family histories. ground size. Many regional communi- the region’s most comprehensive behav- ties are accepting sizable tax increases ioral care for them. Hall-Brooke’s mis- • Many teenagers may display one or more of the problems or “signs” detailed for the sake for new school buildings, in sion includes serving as a regional re- below. The following list describes some potential factors of risk for suicide the belief that spacious, well-equipped source for information on diagnosis and among youth. If observed, a professional evaluation is strongly recom- physical plants are necessary for effec- treatment of mental illness and/or sub- mended: tive learning environments. stance abuse. In line with this, we’re 1. Presence of a psychiatric disorder (e.g., depression, drug or Meanwhile, on the state level, fail- holding informational events which fo- alcohol, behavior disorders, conduct disorder [e.g., runs away ures of an over-burdened, under- cus on the mental health of children and or has been incarcerated]). financed Department of Children and adolescents. 2. The expression/communication of thoughts of suicide, death, dying Families (DCF), have led to the State’s Good mental health effects every part or the afterlife (in a context of sadness, boredom, or negative accession of a shared, but legally domi- of a child’s life: performance in school, feelings). nant, role of the Federal Government in relationships with peers, family dynam- 3. Impulsive and aggressive behavior; frequent expressions of rage. the agency. Other states, also, face cri- ics, and, his or her future. 4. Previous exposure to other’s suicidiality. ses in management of the agencies serv- We must all work to destigmatize 5. Recent severe stressor (e.g., difficulties in dealing with sexual ing their children and families. We’ve mental illness and to provide access for orientation; unplanned pregnancy or other significant real or all read horror stories in the national all children to mental health services, impending loss). press of children lost in various state when these are needed. Then our chil- 6. Family loss of instability; significant family conflict. care systems, and of abuse in foster par- dren will truly be prepared to take soci- ent settings. This does not mean that ety’s future into their hands. Mental Health News - Fairfield County Section: winter 2004 Page 45 Page 46 Mental Health News - Fairfield County Section: Winter 2004

Suicide Services in Connecticut

By Anthony LaBruzza, MD, can also call if they have questions or Ansonia Hartford Plainville Valley Mental Health Center The Samaritans of the Serving North Central Connecticut Chief of Medicine and Jason Spann, concerns about a suicidal family mem- 24 hours / 7 days Capital Region Wheeler Clinic Outreach Clinician, Greater ber. (203) 736-2601 ext. 370 24 hours / 7 days 24 hours / 7 days (860) 232-2121 Helpline: Bridgeport Community Mental In cases where a person is a survivor Branford (860) 747-3434 Health Center, Southwest Connecticut of the suicide of a significant other, it Harbor Health Services Manchester (860) 524-1182 24 hours / 7 days Serving North Central Community Response Team: Mental Health System. Connecticut may be useful to obtain support services (203) 483-2630 Connecticut (860) 747-8719 Department of Mental Health and to deal constructively with the loss. Genisis Center Bridgeport 24 hours / 7 days Stamford Addiction Services Unresolved grief can result in both Southwest Region: Serving (860) 747-3434 Southwest Region: Serving Bridgeport, Darien, Easton, medical and psychological difficulties Fairfield, Greenwich, Monroe, Bridgeport, Darien, Easton, ersons who are dealing with down the road. New Canaan, Norwalk, Stamford, Meriden Fairfield, Greenwich, Monroe, Stratford, Trumbull, Weston, Serving South Central Connecticut New Canaan, Norwalk, suicidal thoughts or gestures Fortunately, there are many sources Westport, & Wilton Stamford, Stratford, Trumbull, Midstate Behavioral Health System often seek assistance from the of information about suicide prevention 24 hours / 7 days Weston, Westport, & Wilton Greater Bridgeport Community mental health community. The services. Residents of Connecticut can Mental Health Center 1-800-567-0902 (203) 630-5305 Franklin S. DuBois Center Plevel of assistance depends on the sever- call Infoline. Below is a description of 24 hours / 7 days 24 hours / 7 days (203) 551-7507 (203) 358-8500 ity of the suicidal action or intent. The Infoline from its website at http:// Middletown Danbury Hospital Serving South Central Torrington first priority is to prevent death or dis- www.infoline.org/: 24 hours / 7 days Connecticut Serving Northwest Connecticut ability from a suicide attempt. The sec- 2-1-1 Infoline is an integrated system (888) 447-3339 Middlesex Hospital Northwest Mental Health 24 hours / 7 days Authority ond step is to treat the underlying condi- of help via the telephone - a single Dayville (860) 344-6496 24 hours / 7 days tion that is prompting the suicidal think- source for information about community Serving Eastern Connecticut (888) 447-3339 24 hours / 7 days Middletown ing. services, referrals to human services, (860) 774-2020 River Valley Services Waterbury In cases where suicide appears immi- and crisis intervention. It is accessed 24 hours / 7 days Serving Northwest Connecticut Derby (860) 344-2100 Waterbury Hospital Psychiatric nent or a person has just made a suicide toll-free from anywhere in Connecticut Griffin Hospital Center attempt, it is best to call 911 and have by simply dialing 2-1-1. It operates 24 24 hours / 7 days Milford 24 hours / 7 days (203) 732-7541 Bridges (203) 573-6500 the person taken to the emergency de- hours a day, 365 days a year. Multilin- 1-800-354-3094 website: www.bridgesmilford.org partment of a local hospital. There gual caseworkers and TDD access is 24 hours / 7 days West Mystic East Hartford (203) 878-6365 Contact of Southeast trained professionals can assess the seri- available. 2-1-1 connects you to agen- Serving North Central Connecticut Connecticut 24 hours / 7 days ousness of the suicidal threat or action cies and organizations near you that can New Haven 1-800-848-1281 and can advise a further course of ac- make a difference. Dial 1-800-203-1234 Intercommunity Mental Health Connecticut Mental Health Center (860) 848-1281 Group 9 a.m. – 10 p.m. tion. outside of Connecticut. 24 hours / 7 days (203) 974-7735 In addition, there are services that (860) 895-3100 (203) 974-7713 provide support groups to survivors In cases where a person is troubled There is also a national database of 10 p.m. – 8 a.m. of suicide: by suicidal thoughts but has no immi- suicide hotlines online at http:// Enfield (203) 974-7300 Serving North Central Bridgeport nent plan or intent, it is advisable for suicidehotlines.com/ where you can sim- Connecticut New Haven Telephone Group that person to discuss such thoughts with ply click on your state and get a list of Clifford W. Beers Guidance Clinic (203) 372-5702 North Central Counseling 24 hours / 7 days a mental health provider. Private insur- services. For those without a computer 24 hours / 7 days 1-888-97-YOUTH Darien ers provide such lists to their subscrib- there is a 24-hour toll free number: 1- (860) 683-8068 1-888-979-6884 Center for Hope (203) 655-4693 ers. Department of Mental Health and 800-SUICIDE or 1-800-784-2433. Hartford Norwich Serving North Central Connecticut Serving Eastern Connecticut Seymour Addiction Services (DMHAS) has a Below is a list of hotlines and crisis ser- Mobile Crisis Service (203) 264-5613 number of crisis services throughout the vices that can assist suicidal persons. Capitol Region Mental Southeastern Mental Health Health Center Authority Wilton state, and non-DMHAS clinics also may These are arranged alphabetically by 24 hours / 7 days 24 hours / 7 days Therapist Led Group provide such services. Family members city or town. (860) 297-0999 (860) 859-9302 (203) 762-7804

Managing the Acutely Suicidal Patient

By Bruce Gussin, PA-C, and tient has loaded firearms in the home and males. However, females are more likely ● Are they giving their possessions Charles J. Morgan, M.D., Chairman has professed his intent to use them “to to attempt suicide than are males. 1999, away? Department of Psychiatry end my suffering.” It is also stated that white males accounted for 72% of all ● Are they assigning responsibility Bridgeport Hospital his father and male first cousin took their suicides. Together, white males and “You need to take care of your brother lives violently. Family reports that the white females accounted for over 90% of when I am gone.” man in his thirties is brought patient has “always been a hard working, all suicides. ● Do they perseverate on their suffering in to your ER by family. Ac- dedicated family man”. He has never had ● 57% of suicides in 2000 were com- or ruminate about their losses? cording to family members he any outpatient or inpatient psychiatric mitted with a firearm. has completely stopped eat- care and has never stated suicidal inten- All of these are essential characteris- A It is also important to understand that tics of a patient at risk for self-harm. ing, lays in bed all day – without sleep- tion in the past. ing- and appears to have lost all will to The above scenario presents the clini- suicide is not only the product of ex- Further discovery of these elements of participate in any meaningful activity or cian as well as the family members with treme depression. Virtually all of the the patients illness serve as evidence of major categories of psychiatric illnesses conversation. When questioned it is elu- many questions. The most important, of suicidality and will provide qualifiable cidated from family that he was in an course, is “what do I do now?” can result in suicide as an endpoint. This markers of improvement when consider- auto accident – for which he blames In providing some guidelines to the list would include: depression, bipolar ing their safety as they begin to improve disorder, schizophrenia, substance abuse, himself – in which his oldest son was above question I would like to start out with treatment. Don’t: killed. This event occurred approxi- with some common background infor- as well as Personality Disorders and de- Minimize or Misunderstand the problem mately one week ago and in the follow- mation on suicide. According to the mentias. Ignoring the potential risk in non-depressed patients can have catas- ● Assume they are not serious ing days he has become completely de- CDC: trophic results. ● Leave the person alone spondent and states only “I deserve to • Suicide took the lives of 29,350 die for what I have done.” The patient When faced with a suicidal patient it ● Involve yourself in contracts of safety Americans in 2000. is important to have a clear understand- also exhibits consistent rumination. He or secrecy ● More people die from suicide than ing of the essential “do’s and don’ts”: plays the events of the accident over and ● Overreact or act shocked over in his head and constantly seeks from homicide. In 2000, there were 1.7 Do: times as many suicides as homicides. ● Threaten, challenge, or dare understanding of blame. Rather than Listen carefully to what patients accept that it was an unfortunate acci- ● Overall, suicide is the 11th leading ● Attempt to involve moral/religious or family members tell you: dent he seeks primarily to find a way to cause of death for all Americans, and is arguments blame himself for the events. According the third leading cause of death for ● Are they hopeless or do they feel When initially evaluating a suicidal young people aged 15-24. to family they are unwilling to leave him helpless? patient/family member/friend it is impor- unattended, even for brief moments, for ● Males are more than four times more ● Do they feel others would be better tant to understand fear that he will harm himself. The pa- likely to die from suicide than are fe- see Managing on page 47 off without them? Mental Health News - Fairfield County Section: winter 2004 Page 47

Interest Becomes Personal

By Emily Byrne, APRN hearts of the bereaved aches with a Norwalk Hospital chronic, corrosive pain. Haunted by the agonizing question, why, we dig for uicide has been an interest of answers. Some dig through memories, mine for years. It began as a sifting through pictures, belongings, and fascination of the infernal mad- letters. I dig with my pen. S ness and creative brilliance of As clinicians we have a great deal of writers such as Plath, Sexton, and knowledge of psychopathology and sui- Woolf. These writers, among many cide. We understand the black and artists, died a self-inflicted death. white statistics. Suicide is a national My interest became a personal, chill- health problem that claims the lives of ing reality three years ago. October 30, 30,000 people each year. Each day ap- 2000 a close friend from high school proximately 80 Americans die a suicidal killed himself by rope. The news sur- death. This equates to 1 person every 18 prised many, but shocked few. Beneath minutes. It is the third leading cause of the surface of outward successes was a death of young people and the second man tormented by dark moods and among college students. We know that manic temperaments. He suffered and most suicides occur in people suffering self medicated with drugs and alcohol. from mental illness and substance abuse. Family and friends reached out, but he We know that that the highest risk popu- slipped deeper into his private night- lations are the elderly (65+ years) and mare. At his funeral and the days and the young (15-24 years). There is a gen- months that followed we wrestled with der bias with women 3-4x more likely to the sense of having failed. attempt suicide and men 4x more likely Three months later my best friend to kill themselves. Statistics reveal a from college ended his life by bullet. seasonal variation with late spring and The call from his mother came three summer having the highest rates of sui- days after his 27th birthday, forty-eight cide. We know that attempted suicide is hours after I had last spoken to him. I the single most powerful predictor of replayed our last conversation over and subsequent suicide. Despite all that we over searching for clues. His final know, we are left asking why? words to me, ‘never sacrifice your crea- The depth of psychological pain and tivity for security.’ I promised and we despair that closes the mind and heart to said goodbye. life is a private experience. Sufferers The emotional weight of the experi- experiencing that extent of hopelessness ence broke me. Time seized. I was may isolate, making a clinical snapshot paralyzed by pain, suffocated by guilt, difficult. Assessment of suicide risk can and lost in a chaotic hopelessness that be captured at every clinical encounter. permeated everything. My hollow exis- Directly asking about suicidal thoughts tence became one of isolation and frag- and intent, evaluating levels of agitation mentation. Each day my breath grew and anxiety, inquiring about sleep dis- more shallow and sour. I felt life bleed turbances, and recent causes of stress from my necrotic body. Fortunately my can help identify a client at risk. Some unraveling and plunge was quick. Re- segments of the population’s suicide covery was painfully slow. It was over a rates have dropped, while others con- year before I felt the wings of hope tinue to rise. As clinicians and as a na- again. Time eases the hurt, but the miss- tion we need to not only ask why, but ing remains. The hole burned in the how can we make a difference.

Managing from page 46 The most important aspect of under- standing when a patient can be dis- the varying degrees of care available. charged from care, safely return to their Understanding that suicidal persons pre- environment, is this information we sent with a variety of presentations is gather initially. Since the presentation of often a mystery to the lay person. suicidal patients vary so widely it is cru- Should we worry more about the emo- cial to be able to see what has changed tionally labile screamer or the which would represent that they are no quiet/withdrawn sleeper? The answer is longer a danger to harm themselves. In that a suicidal threat needs to be taken the above case presentation it was our seriously despite the presentation. The belief that once his constant rumination first step can be to continue to attend to was alleviated the patient would no the person while contacting their private longer represent a risk. In other patients counselor or physician or it could be an immediate trip to the ER. The benefits it could be the cessation of auditory hal- of hospital care are multifold. First and lucinations or an improvement/change in foremost would be the enhanced safety their home situation. Either way the that a monitored unit can provide. More most important element is change. For important though, is the wide range of this reason it is essential that the treat- talents and backgrounds that can be pro- ment team is constantly evaluating the vided by the interdisciplinary nature of patient for suicidal risk, not just at ad- the inpatient unit. Often the first step in mission and discharge. Although we can fighting depression is the bond forma- never guarantee that a patient is abso- tion that can occur between patient and lutely no risk to themselves, by consis- caregiver whether it be Nursing, Medi- tent evaluation with an eye toward cal Team (Psychiatrist, Physician Assis- changes in presentation over time, we tant, Nurse Practitioner), Recreation can present our safest estimation and therapy, Social Work or other patient. minimize tragic outcomes. Page 48 Mental Health News - Fairfield County Section: winter 2004

Why Do People Kill Themselves ?

By Sigurd Ackerman, M.D. family history of suicide seems to for the belief that asking a depressed tality was partly intentional. President and Medical Director increase the risk of suicide inde- person about suicide may plant an In certain personality disorders, Silver Hill Hospital pendently of mental disorders. Ge- idea that wasn’t there already there. such as the borderline personality netic factors may be important inde- Conversely, a person’s denial of disorder, the patient has a greater pendently of mental disorders. And, suicidal intent does not mean he proclivity for attempting suicide, as I said initially, for some the deci- won’t attempt to kill himself). In even if ambivalently. This, too, is a sion to end their lives also seems to addition, information about other serious situation because some of be independent of any mental disor- risk factors is extremely important, those attempts are successful. How- der. But starting with the assump- including a past history of suicide ever, treatment is difficult and re- tion that the proclivity to harm one- attempts, a history of suicide in first quires a change in the person’s sta- self is part of a mental disorder degree relatives, current substance ble traits, as distinct from the treat- maximizes the chances of prevent- abuse, a history of childhood sexual ment of a transient, episodic state ing self harm by maximizing the abuse, impulsivity and aggressive- disorder such as depression. Long chances that the person will soon ness as prominent personality traits term treatments of patients with per- have a change of heart. and lack of social and family sup- sonality disorders typically focus on However, this last statement by ports. learning to use new coping mecha- itself raises more questions than it When the consideration of the nisms to deal with anger, loss, de- answers. What are the mental disor- depressed person’s current mental pressed mood, a sense of emptiness ders that are associated with sui- state and these risk factors suggest or sensitivity to rejection. cide? Can one predict in advance an increased risk for suicide, hospi- Should we always start with the which person with one of those dis- talization is often the safest course. assumption that the wish to kill one- orders will actually attempt suicide? With proper treatment there is a Sigurd Ackerman, M.D. self is a temporary, reversible aber- Is the assessment of suicide risk the high likelihood of recovery from ration? A dramatic argument for same for all disorders? depression and, with that, a dramatic why we should can be found in an For convenience we can talk change of mind about suicide. How- article by Tad Friend in the October hy would someone about four groups of mental disor- ever, this recovery takes time and, 13, 2003, issue of New Yorker commit suicide? ders that are associated with suicide. with hospitalization, one buys time. Magazine. Friend gave a short his- In episodes of psychosis, such as There are many an- This list in not exhaustive but it tory of suicides carried out by jump- in an acute exacerbation of a schizo- W swers to this ques- helps in organizing our thinking ing from San Francisco’s Golden tion but, for my purposes in this about the topic. The groups to which phrenic disorder the situation can be Gate Bridge. Astonishingly, these brief article, they fall into two very I am referring are the mood disor- quite different. The patient might occur on average about once every different groups. A few people end ders (depression and bipolar disor- experience voices that tell him to two weeks – or a total of more than their lives as part of a more or less ders), schizophrenia and other disor- kill himself or have a delusional 1200 suicides since the opening of rational decision when, in the course ders which cause psychosis, sub- thought which includes the notion of the bridge in 1937. Of this vast of a terminal illness or other dire stance-abuse disorders and certain self harm. In such situations the pa- number only 26 persons are known circumstance beyond their control, personality disorders. tients potential for actual self harm to have survived. Friend interviewed they find no prospect for an accept- Most persons who commit sui- is much more unpredictable and able or even bearable quality of life. cide do so in the midst of an episode therefore more difficult to assess those he could find, two of whom However, the vast majority of of depression. In addition to its af- with a risk-factor approach. If such gave chilling accounts of regretting suicides occur as part of a mental fect on mood depression has a pro- symptoms cannot be changed very their decision to jump as soon as illness. This, of course, is the group found effect on cognition – the way rapidly by treatment with neurolep- they left the bridge. Conversely, he that is of most interest to psychia- we think. Thoughts in depression tic (antipsychotic) medication, most reports a study of 515 persons who trists and other mental health work- often turn to guilty self recrimina- mental health workers would move were thwarted in their attempts to ers. The notion that suicide is almost tions, the idea that one does not for hospitalization to keep the pa- jump. In a follow up of, on average, always related to a mental disorder have intrinsic worth and the idea tient out of harms way until symp- 26 years, 94 per cent of the would- is controversial but nonetheless one that there is no hope for a brighter tom remission does occur. be suicides were still alive or died of of great significance. If the state of future. In this context, the idea of Substance abuse disorders have natural causes. mind that prompts the impulse to ending one’s life can become ap- an independent risk for suicide, The main point I am making is end one’s life is part of a reversible pealing. probably because acute intoxication that the wish to kill oneself is most episode of a mental disorder then Evaluating the suicide risk in a can cause a rapid change mood in often transient and reversible. the suicidal state of mind will go depressed person is based on a care- association with changes in thinking Whether you start by identifying away when the disorder is success- ful assessment of such thoughts with and in judgment. In addition when mental illness or by identifying sui- fully treated. special attention paid to how the an acutely intoxicated person dies in cidal intent the interface between The “mental disorder” perspec- person views suicide and whether he a fatal accident, such as a one-car them provides the greatest opportu- tive does not mean that other factors or she may have made plans to end collision, it is often difficult to de- nity to offer help and perhaps save a are not important. For example, a his/her life. (There is no basis in fact termine the extent to which the fa- life.

Mental Health News Understands That The Holidays Can Be A Difficult Time If You are Feeling Alone and Hopeless: Don’t Be Ashamed To Ask For Help There Is a Caring Mental Health Community Nearby and Ready To Help You Feel Better Mental Health News - Fairfield County Section: winter 2004 Page 49

The Choice For Psychiatric Treatment

You will find a team of caring and dedicated experts in the field of mental health and substance abuse to support you and your loved ones on the journey to wellness. Our staff, our use of the state-of-the-art treatment methods and 60 acres of beautiful New England countryside offer a unique and outstanding formula for treatment and recovery. PAGE 50 MENTAL HEALTH NEWS ~ WINTER 2004 Hudson from page 10 include sales associate, home health aide, junior machinist, tutor, cashier, dietary is committed to supporting community aide, library assistant and substitute Suicide: rehabilitation approaches that are innova- teacher. Mary works approximately 30 tive and have proven to make a difference hours per week. The regional average in the lives of individuals with severe work week is just over 24 hours. An Addictive Behavior mental illness. This commitment is re- The central theme that weaves its way flected in a mindful way through OMH’s through all of OMH’s service delivery By Robert M. Lichtman, Ph.D., DAPA support of evidence-based practices such designs in the Hudson River region and Rockland Psychiatric Center as supported employment. Research has around the state is the value of hope and shown that rapid integration into commu- recovery. Recovery is a living process at aniel was intent on killing nity vocational settings, with appropriate the Liberty House Foundation in Glens himself. He threatened his supports, has a major impact on an indi- Falls, NY. Liberty House is a not-for- outpatient treating team and vidual’s recovery. Best practices are one profit clubhouse modeled after Fountain his family, that if he did not of OMH’s basic tenets for service en- House in NYC. Every day members and Dreceive a prescription for Ativan, a hancement that also includes Account- staff work side by side to facilitate the highly addictive anti-anxiety drug, he ability and Care Coordination - the operation of the clubhouse. Along with a was going to drink himself to death. In ABC’s. mobile work crew and a transitional vol- order to prevent this, his family had Empirical research indicates that the unteer program, Liberty House offers taken him to a psychiatric emergency supported employment model of voca- transitional, assistive competitive and room, where he was hospitalized as a tional rehabilitation has strong positive independent employment choices for danger to himself. Once again he began outcomes for individuals with severe members. to demand that the ward psychiatrist mental illness. The key components of The stabilizing effects of Liberty’s this model are: rapid job searches and clubhouse design equates to an increase give him the drug. As with most chemi- Robert M. Lichtman, Ph.D. cally dependent patients receiving effi- placement, employment settings based on in job tenure for program recipients. On cacious treatment, he did not receive it. a psychological "autopsy" and a root recipient choice, follow along supports average, members are employed in inte- He then persuaded his family into taking cause analysis it was determined that that are unlimited, integration with the grated, competitive settings for a period him home, promising that he would not Daniel "was going to do what he was mental health clinical team and a strong of 72 months. The average work week is harm himself. Unfortunately they be- going to do," the culpability was his provider commitment with the under- 34 hours. Liberty House’s placement rate standing that competitive employment is is 74%. lieved him and came to the hospital own. I have often reflected on Daniel's an obtainable goal for anyone with a de- Marie, a clubhouse member, has been signing him out AMA (Against Medical case and his drive to kill himself, think- sire to work. The emphasis is not on long- in her current assisted competitive em- Advice). Once home and out of his fam- ing "short of locking him up, and throw- term prevocational readiness develop- ployment (ACE) position for six years ily's sight he secured the anti-anxiety ing away the key," did we do everything ment. now. She originally went back to the job drug on the street, bought a liter of clinically possible to prevent that sui- Supported employment, as an evi- that she was discharged from prior to the vodka, rented a room in a local motor cide? The question haunts me to this dence-based practice, allows for service onset of her mental illness. She is now a inn and successfully committed suicide. day. The concepts of free will and self- provision to be benchmarked in a more registrar for patient access in the emer- The combination of the anti-anxiety determination are challenging when objective fashion. Fidelity to the model gency room of an area hospital. Marie drug and the vodka proved to be quite someone takes their own life. design, for any supported employment values the ongoing, unlimited support that lethal, and he knew it would. Following see Addictive on page 53 provider, can be measured through instru- the clubhouse provides. Previous attempts ments like the Quality of Supported Em- at complete independence resulted in ployment Implementation Scale (QSEIS). repeated hospitalizations. A placement The efficacy of supported employment manager sees her at work approximately has been well documented. Treatment two times each week. She is also an ac- American Association of Suicidology designs in controlled settings have proven tive member at the clubhouse which she

to work. The effectiveness of these ser- says, “recharges her batteries”. vices, in the community, has been unfold- Blended mental health services and a THE LINKS BETWEEN DEPRESSION AND SUICIDE ing and the results are very positive. The supportive clubhouse model are just two latest comparable supported employment examples of effective supported employ- • Major depression is the psychiatric diagnosis most commonly data indicates that integrated placement ment programs in the Hudson River re- rates, for individuals in SE programs gion. These programs are making a differ- associated with suicide. within the Hudson River region is 39% ence. John, a former carpenter for 27 • About 2/3 of people who complete suicide are depressed at (statewide 28%). OMH’s Hudson River years who was placed by Gateway’s mile- the time of their deaths. region extends from Westchester County stone project at a local building supply north to Warren and Washington Coun- company, put it best when he said, “Work • One out of every sixteen people who are diagnosed with ties in the Adirondacks. There are two makes me feel more normal, it makes me depression eventually go on to end their lives through suicide. milestone project contractors within this feel like a human being.”

region, Gateway Community Services • About 7 out of every hundred men and 1 out of every hundred and Westchester MHA. Placement rates, You may contact Jack Smitka at the women who have been diagnosed with depression in their after screening, for these two programs NYS Office of Mental Health, Hudson lifetime will go on to complete suicide. averages 60%. Employment positions River Field Office at (845) 454-8229. • The risk of suicide in people with major depression is about 20 times that of the general population.

• People who have had multiple episodes of depression are at greater risk for suicide than those who have had one episode. INFO LINE People who have a dependence on alcohol or drugs in PSYCH • addition to being depressed are at greater risk for suicide. A SERVICE OF THE PSYCHIATRIC SOCIETY OF WESTCHESTER

• People who are depressed and exhibit the following symptoms are at particular risk for suicide: 914-967-6810 This is an information and referral service sponsored by the Westchester 1. Extreme hopelessness District Branch of the American Psychiatric Association.

2. A lack of interest in activities that were previously pleasurable Psychiatrists of this organization are dedicated to providing treatment for 3. Heightened anxiety and/or panic attacks mental disorders and advocating for equal health care for mental and physical conditions. 4. Global insomnia If you need information about psychiatry or assistance in finding 5. Talk about suicide or a prior history of attempts/acts a psychiatric physician - please call us. 6. Irritability and agitation THE PSYCHIATRIC SOCIETY OF WESTCHESTER 555 THEODORE FREMD AVENUE • SUITE B-100 • RYE • NEW YORK MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 51

Youth Suicide: Building Bridges Through Community Outreach

By Ari Kellner, Psy.D. clear warning signs of potentially dan- • Develop broad-based support for • Promote and support research on The Mental Health Association gerous behavior. For example, a high youth suicide prevention. youth suicide and youth suicide preven- of Westchester school student who feels depressed, is tion. abusing alcohol and drugs, has a history • Design and implement strategies to of very impulsive behavior, and has ac- reduce the stigma associated with being The pain and loss behind the previ- uicide ranks as the third leading cess to highly lethal methods to attempt a youth consumer of mental health, sub- ously mentioned statistics are why we cause of death for young people suicide is at much greater risk than that stance abuse and suicide prevention ser- need to act now. We must accept that (ages 15-24); only accidents same student who is feeling depressed vices. the problem of youth suicide is too large S and homicides occur more fre- without the other risk factors. Fortu- to handle alone and many of our answers quently. Approximately 12 young peo- nately, many risk factors can be reduced • Identify, develop, implement and begin through partnership. The follow- ple between the ages of 15-24 die every or moderated by protective factors. evaluate youth suicide prevention pro- ing are a list of informative suicide web- day by suicide. In 1998, more teenagers One of the most important protective grams. sites: and young adults died from suicide than factors is helping young people receive American Association of Suicidology from cancer, heart disease, AIDS, birth the appropriate clinical care for mental, • Promote efforts to reduce access to defects, stroke, and chronic lung disease physical, and substance abuse disorders www.suicidology.org lethal means and methods of self-harm. combined (Surgeon General, National they may be experiencing. This process Statistics). Suicide rates of 15-24 years is greatly aided when youth have easy American Foundation for Suicide • Implement training for recognition Prevention www.afsp.org olds are 300% higher than those of the access to a variety of clinical interven- of at-risk behavior and delivery of effec- 1950’s, and have remained largely stable tions and feel supported by their commu- tive treatment. Mental Health Association of West- at these higher levels between the late nity and family for seeking help. chester www.mhawestchester.org

1970’s and the mid 1990’s. Suicide One vital way of developing easy • Develop and promote effective rates of children between the ages of 10 access to clinical care is through an open National Strategy for Suicide Prevention clinical and professional practices. www.mentalhealth.org to 14 years increased 99% between 1980 and collaborative relationship between and 1997, with slight declines in recent community mental health providers and • Improve access to community link- years. More troubling than these statis- the surrounding schools, faith-based Suicide Hotlines ages with mental health and substance tics is our knowledge that there are far organizations, healthcare professionals, www.suicidehotlines.com abuse services. more suicide attempts and gestures than and other public and private community

actual completed suicides. Nationwide, partners. Ari Kellner, Psy.D. is trained as a • Improve reporting and portrayals of nearly one in five high school students Through successful collaboration we School/Clinical Psychologist. He works suicidal behavior, mental illness, and have stated on self-report surveys that begin to ensure that our prevention plans for the Northern Westchester Counseling substance abuse in media and entertain- they have seriously considered attempt- are comprehensive enough to address the Center in Mt. Kisco, NY and has a pri- ment. ing suicide during the preceding 12 complexities of the problem; promote vate practice in Katonah, NY.

months (American Association Suicidol- collective ownership of the problem,

ogy). engage organizations that may not have

Why would so many young people considered suicide prevention within end their lives? The answers are com- their purview, avoid duplications of ef- plex and elude our desires for simplistic, forts, and leverage resources to fund clear, cause and effect relationships. projects that will address the greatest Northern Westchester Instead, suicidal behavior is the end re- need and make the most impact (U.S. Counseling Center* sult of an interaction between multiple Dept. of Health, Sybil K. Goldman). In factors, which may be of a psychiatric, addition, youth who are known to be at A Community Resource for Northern Westchester Communities social, and environmental nature. risk often receive services and help from Stillion, McDowell, and May have a variety of agencies. Through inter- • Child, adolescent, family, adult and senior counseling and support outlined their suicide trajectory model agency communication service delivery including individual, family and group therapy which suggests that there are four major can become more integrated and less • Specializing in child and adolescent services categories of risk factors that contribute fragmented. Consistent contact between • Parent education to suicidal behavior at every age: bio- agencies can clarify what other service • Trauma and Crisis Services logical, psychological, cognitive, and providers are doing, what services are environmental. Each of these categories already in place, or what information is • Domestic Violence Services of risk factors may directly influence already available to help understand a • Medication evaluation and treatment suicidal ideation and may affect other person’s needs. • Nuestro Futuro – Our Future, bilingual/bicultural services for Latino categories of risk factors. For example, Schools can play a unique role in this population having a biological inclination toward process. As several researchers have • Day and evening hours depression can directly affect suicidal pointed out, suicidal children and adoles- • Reduced Fee Option/ Medicaid and most insurances accepted ideation and, at the same time, cause a cents are much more likely to come in person to develop low self-esteem and to contact with potential help in the school • Licensed by NYS Office of Mental Health interpret environmental events in a selec- environment as opposed to other com- tively negative fashion. Likewise, poor munity settings (NIMH, CDC, Surgeon 344 Main Street, Suite 301 environmental conditions, such as an General). Frequently, a child’s prob- Mount Kisco, NY 10549 abusive or neglectful home, can elicit lems, particularly those related to aca- suicidal ideation and also may be a demics or the peer group, are more evi- (914) 666-4646 source of low self-esteem. Some of the dent in the school than in the home. In www.mhawestchester.org strongest risk factors for attempted sui- addition, the home situation may be dys- cide in youth are depression, alcohol or functional; while not necessarily a direct a program of other drug use disorders, aggressive or cause of suicidal behavior, the possibil- disruptive behavior and access to lethal ity of help in that setting is greatly re- means of self-harm. duced. Understanding these risk factors can Some of the areas that may be ad-

help dispel the myths that suicide is a dressed through community collabora- random act or results from stress alone. tion may include the following: It is also important to note that one risk factor is seldom sufficient to trigger sui- • Promote awareness that youth sui- cidal behavior; often a young person cide is a public health problem that is exhibits multiple risk factors that are preventable. *Formerly Northern Westchester Guidance Clinic PAGE 52 MENTAL HEALTH NEWS ~ WINTER 2004

Association of Behavioral Healthcare Management Losing Weight: New York Chapter

It’s A Mind Thing ! One Day Conference Marypat S. Hughes M.S.,R.D.,CD/N not forget to include drinks and snacks Spokesperson for the ADA while watching TV. Become aware of portion sizes and read labels so you are re you turning to food be- aware the portion size of your favorite Behavioral Health cause you are feeling alone snacks. or terribly lonely? Is food the Confusing foods with feelings Management Institute A only thing that makes you (emotional eating) is very common. feel calm, even happy? You are not Most of us do not eat just for nutritional alone if you are eating out of control. replenishment. For most of us meals are Many people eat when they are under indicators of milestones in our days. We June 25, 2004 extreme stress. Some people may agree all have strong feelings about foods we that all you have to do to stop the weight like or dislike. Foods are part of reli- 9:00 a.m. - 3:30 p.m. gain is put down the fork. Fortunately, gious rituals, celebrations and social the weight gain that comes from over- activities. Eating can also be triggered Grand Hotel, Poughkeepsie, New York eating can be prevented. The secret is to by a single emotion or several. Eating understand the effect stress is having on can be triggered by confusion or emo- you so you can adjust your lifestyle and tional distress. Ask yourself, “what am I Keynote Speaker: eating habits-accordingly. feeling?” Am I stressed, bored or feeling Sixty one per cent of U.S. adults are unloved? Mary Cesare-Murphy, Ph.D. overweight. Research is starting to show For some people an emotion may that the greatest barrier to weight loss is Executive Director trigger the craving of certain types of not your genes or constant craving for food. Keeping a food diary may be Behavioral Healthcare Accreditation Services carbohydrates-it is your mind set. helpful information in identifying your Joint Commission on Accreditation of Healthcare Organizations Let us try to leave the old mind set behind and recognize the unhealthy way eating patterns. After you have this in- For Information and Brochure: we eat or our weight will continue to formation you will be able to assess Mark Gustin grow. Luckily, it isn’t tough to reverse where you need to focus your attention. Conference Chair the process. You need to set limits re- Do you find that you responded to emo- garding food and you need to nurture tional arousal or are you not sure what yourself. you were feeling? (516) 791-5289 Experts have made it clear that as our Awareness of emotional eating pat- weight increases we are also increasing terns makes control straightforward. the odds of being at risk for diabetes, You will become aware if you eat just high blood pressure and heart disease. because food is always around you. Very often our self esteem topples be- You may begin to stop and become cause we lose our self confidence to aware if you are eating because you are break free of the fattening mind set. hungry or if you are eating out of bad Suicide We feel inadequate about being able to habits. Listen to your emotions when make healthy food selections. they come up. Instead of turning to Many people have found ways to food, try and relax with yoga or going And Mental Illness successfully manage their mental illness. for a walk. In order for success, whether it is for Be respectful of your body. Value it, By Martin Gittelman, Editor result of suicide. A review of the litera- weight loss or stopping further weight exercise it and choose healthy foods to International Journal of Mental Health ture shows that persons with mental ill- gain challenging shifts must take place. nourish it. Try not to reach for food in ness commit suicide at a rate at least 9 To break out of an unhealthy situation order to push away painful feelings. To times more than persons without mental we all need a little direction and clear face such emotions you may want to ne of the major causes of illness ( Harris, C. and Barraclough, goals to move to a more positive place. enlist the aid of your psychiatrist. You premature death is suicide. It B.M. Suicide as an outcome for mental Secrets to Winning The Mental Game need support and the support can teach is good that Mental Health disorders, British Journal Psychiatry, you to be self-reflective and to come up O News is drawing attention to 170,1997). Mental illness need not and First, set attainable daily goals. Eat with solutions other than food. After the issue of suicide among persons with should not be fatal. Yet the evidence is five or six times a day to avoid feeling you realize the problems, be assertive mental illness. Relatively little attention clear that these disorders are associated hungry. Focus on including fruits, vege- and come up with a plan to put yourself has been paid to the phenomena of pre- with risk factors which lead to prema- tables and complex carbohydrates, first. Do something kind for yourself- ventable and premature death among ture death and suicide. Cassadebaig which help you feel full. Do not make make up your mind to take good care of persons with mental illness nor to the (1999, L’Encencephale,25,329-37) has unreasonable demands on yourself. Set yourself. Figure out what is normal for risk factors which increase morbidity stated that studies of mortality among reasonable goals and be gentle with you and stop eating when you are full. and mortality. The President’s New persons with mental illness are good yourself. Be sure to include exercise. If you do not really enjoy what you are Freedom Commission Report has drawn indicators of the quality of care they If you achieve your small goals you will renewed attention by citing that some receive or do not receive. feel good about yourself. When we try eating, do not feel like you have to finish 30,000 persons commit suicide and each As we seek to understand the factors to take big steps beyond our capacity it. It is okay to throw food away. year 650,000 persons require emergency which make for high suicide rates and relapse tends to occur. Try not to be hard Change your behavior to include care following a suicide attempt. While short life expectancy among persons on yourself and tell yourself that you can more fruits and veggies. Monitor your the annual figure of 30,000 who die with mental illness we need to look at only do so much and try to do things changes. Realize that it will take some from suicide is the same as the number known factors which make for shortened that are good for you. time to adjust. Focus on planning who die from HIV-AIDS, suicide has life. M.Harvey Brenner in his classic Self acceptance is important. Feel healthy meals and snacks. Resist skip- received much less attention in the me- study on the consequences of unemploy- good about who you are. Repeat daily ping meals—research shows you tend to dia. ment found that for every 1% increase in affirmations such as “I like myself” and overeat if you eat when you are over We’ve known for many years that unemployment there was an increase of “ I am a worthwhile person”. Once you hungry. It takes four hours for your persons with mental illness die prema- 10,000 deaths from a myriad of proxi- accept yourself, you stop blaming others body to digest an average meal or snack. turely because of many and complex mal causes, including suicide. Unem- and you can begin to take control. If you are eating more frequently, you factors. Cliff Levy in his Pulitzer prize ployment, homelessness, tobacco addic- Break the old patterns by keeping track are eating too much. Too much food winning recent series on nursing homes tion, alcoholism, substance abuse, pov- of how often you eat and what you eat. gives you extra calories which leads to in NYC found that persons with severe erty are all factors associated with Jot down times during the day and night weight gain. mental illness died at an average life when you are eating. List all the extras expectancy of 58 years, many as the see Suicide on page 53 like butter, seasonings and toppings-do see Mind Thing on page 56 MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 53

Addictive from page 50 When Ingestive Addictions Become Process Addictions Running on Empty New Internet Dating Site For Specialists in addictive disorders Daniel was neither religious nor usually separate behaviors that involve spiritual. Church and self-help programs the administration of substances into one Adults with Mental Illness held little value for him. The central category and others like pathological activity in his life was to remain in the gambling, shoplifting, exercising, the Staff Writer finding each other often poses a difficult altered sense of consciousness produced internet, and sexual compulsivity into Mental Health News challenge. It is my hope with this web- by the psychoactive properties of an another. Hence the terms ingestive and site that finding and securing meaningful anti-anxiety drug. When the drug was process. They are not mutually exclu- or the heroic men and women relationships, whether friendship or ro- not available, alcohol took its place— sive, as people engage in both and at fighting mental illness in this mance, will be easier for those who sign not his drug of choice, Ativan was. Al- times simultaneously. I prefer to call the country, NoLongerLonely.Com up for membership. My goal is to liter- cohol drove him into misery and made latter "Addictions Without Substance," is filling a need and offering ally make those with mental illness ‘No his hunger for Ativan worse. Daniel in although both have a payoff in the form Fwelcome relief with a safe, secure, and Longer Lonely’.” an alcohol intoxicated state was literally of physiological, psychological, and free way to find companionship. The NoLongerLonely offers a broad array hopeless, hapless, and helpless. He was sociological reinforcement. Anecdotally, billion-dollar online dating industry is of features that the larger dating sites running on empty, unable to fill himself, I have seen a number of cases where the finally reaching those who need it most: have made standard such as anonymous and the alcohol was a poor second place person's life ended in an intentional sui- the mentally ill. emailing, photo upload, proximity substitute. It was the lure of Ativan that cide, either by design, as in Daniel's Webmaster James Leftwich under- searching, detailed matching criteria, E- kept him going. He could not tolerate case, or by moral deterioration, to a stands the trials and tribulations of man- mail notifications, a chat room, and soon the protracted withdrawal enforced by point where an "accident" takes the per- aging a mental illness. Since being di- a section for members to submit original the controlled environment of a hospital son's life. When there is literally nothing agnosed with Schizoaffective Disorder articles, essays, and artworks. ward or a locked rehabilitation program. more to live for other than seeing one- in 1992, Mr. Leftwich has secured a Leftwich has made guaranteeing the He went through countless detoxifica- self being strangled and falling deeper Bachelor’s Degree and a Master’s De- privacy and anonymity of his users a top tion and rehab programs, both inpatient into an abyss, suicide is no longer seen gree and is now pursuing a career in priority, “It is understandable that users and outpatient. His comfortable state as an option. The drive towards dying librarianship. Confident that there were will be wary of disclosing they have a was his addicted state, and without the takes on all of the properties of addictive thousands of other such “recoveries” mental condition. For this reason all anti-anxiety drug in his system he was behavior, especially the obsessive and across the United States, Leftwich contact between users is under the head- very uncomfortable. As with many sub- compulsive components. It is no longer launched NoLongerLonely. ing of a fictitious username. Their only stance dependent people his tolerance seen as some clinicians say "a perma- According to Mr. Leftwich, “Social real identifying mark is their photo if increased exponentially to a point where nent solution to an otherwise temporary isolation is a hallmark symptom of men- they choose to upload one. It is also he required four times the dosage indi- problem," it becomes the "solution" it- tal illness. The general public is basi- important to remember that anyone us- cated for someone with an anxiety disor- self. The drive towards oblivion is all cally indifferent and often hostile to ing the site also has a mental condition.” der. Other medications were tried, all to too powerful. those struggling to re-integrate with so- Membership at NoLongerLonely is no avail. They only made him tired and ciety. In my experience, most mentally completely free of charge during this produced sleep. Once awake the craving Dr. Lichtman is a specialist in the ill people tend to group together but rollout period. returned twofold. He could not live in assessment and care of people who have his skin; the pain was too great. The co-occurring emotional and substance addiction to the drug was now turning use disorders. He is a faculty member at towards the drive towards death. He saw John Jay College of Criminal Justice his life ending as the only way out of his and the Ferkauf Graduate School of misery; it had become an addiction to Psychology, Yeshiva University, Albert suicide. Einstein College of Medicine.

Suicide from page 52 and rehabilitation, "getting the govern- A New Internet Dating Site ment off the backs of the people" increased risk for illness, premature and the introduction of managed care death and suicide. has failed to fulfill the promise of im- For People With Mental Illness The recent President’s Freedom proved care which could stem high mor- Make Friends or Meet Potential Dates Commission Report on Mental Health tality among persons with mental ill- has informed us about some of the rea- ness. We now spend more on treat- Take Advantage of Free Membership Now sons for increased morbidity and mortal- ment and care than any other country in ity. The Commission found that only the world, yet our suicide and attempted about half the people who require assis- suicide rates are among the highest in www.NoLongerLonely.Com tance are receiving such assistance. In the world. the Commissions’ words, our mental What can and should be done about health delivery system is in the problem of suicide and premature "shambles". The Commission’s Report death among those with mental illness? of 30,000 suicides with 90% associated In recent years we have seen the growth with mental illness - a "wake up" call to of the family and mental health con- action, yet the report seemed to have sumer movement along with other advo- attracted little editorial comment. cacy groups such as the Mental Health Since the recession by President Association and American Association Reagan of the Mental Health Systems for Psychosocial Rehabilitation. Such Act of 1979 at the time of his inaugura- groups have yet to truly fulfill their roles tion and the subsequent de-funding and as advocates to press for improvements closure of Community Mental Health in the organization and delivery of men- Centers we have seen increased prob- tal health care. We need to do a better lems with our mental health sys- job to deal with this problem of suicide tem. While there are some fine exam- and premature death among persons ples of comprehensive care, treatment with mental illness.

Get Your Message Out ! P.O. Box 635 Orangeburg, NY 10965 Advertise in Mental Health News (845) 359-8787 PAGE 54 MENTAL HEALTH NEWS ~ WINTER 2004

Helping Families from page 27 death. It also can lead to major, unneces- sary surgery. We may not feel we de- In a situation of this type, a family mem- serve to live happily since our beloved is Human Development ber can become frightened and may even gone. Guilt after death is just over- feel that they have somehow hurt the whelming. patient and caused the suicide. In the case of a child dying in the Services of Westchester It may feel unacceptable to express family, spouses usually blame each angry feelings or personal hurts at a time other. All the times they did not love like this. Actually, a clear, honest ex- enough now appear in front of their eyes Creating Community pression of our feelings can work to re- to be reckoned with. lieve and soothe the situation in many “I just couldn't look at my husband ways. Otherwise this anger is projected after Tommy was gone. I kept feeling he • Human Development Services of Westchester serves adults and families who towards other family members, or to- was blaming me, thinking if I had only are recovering from episodes of serious mental illness, and are preparing to wards ourself causing illness, separation been a better mother, more patient and live independently. Some have had long periods of homelessness and come directly from the shelter system and many other harmful consequences. caring, this never would have happened. Families often react by bottling up I kept wondering if he thought Tommy • In the Residential Program, our staff works with each resident to select the their feelings and trying to hide how might have wanted to die. Neither of us level of supportive housing and the specific rehabilitation services which will upset they are. In the long run this is could part with what was left of his bicy- assist the person to improve his or her self-care and life skills, with the goal of detrimental. It gives less and less reality cle. Even though the other children des- returning to a more satisfying and independent lifestyle. to the situation, creating only distance. It perately needed our family to remain is healthier to acknowledge and carefully together, my husband and I separated • The Housing Services Program, available to low and moderate income express resentment or disappointment. that year. We just couldn't take it.” individuals and families in Port Chester through the Neighborhood We can express our personal reac- Blame cries out to be looked at and Preservation Company, includes tenant assistance, eviction prevention, home tions without casting blame. Just simply understood as a perfect example of our ownership counseling, landlord-tenant mediation and housing court assistance. communicate what you are feeling now. own lack of comprehension of loss and Say, “This is how I am feeling now. misplaced sense of responsibility. • Hope House is a place where persons recovering from mental illness can find This is what I'm thinking”. One takes Families need to realize that they are the support and resources they need to pursue their vocational and educational responsibility for one's own feelings and not and never have been in control of the goals. Located in Port Chester, the Clubhouse is open 365 days a year and draws members from throughout the region. thoughts and does not imply that another patient's life. No matter how much they caused you to feel these feelings. care for the patient, ultimately each per- • In the Case Management Program, HDSW staff provides rehabilitation and No one causes you to feel what you son must answer for themselves. support services to persons recovering from psychiatric illness so that they feel. Things out there happen, and you Helping Each Other Heal may maintain their stability in the community. can react to them in many different ways. You are not necessarily responsi- As family members attempt to cope ble for what has happened, but for how with this event, one member sometimes becomes so identified with another that you are responding to it. And what you HDSW HOPE HOUSE choose to do with it. they become confused about their differ- 930 Mamaroneck Avenue 100 Abendroth Avenue ing responses and needs. They believe Mamaroneck, NY 10543 Port Chester, NY 10573 Relinquishing Blame everyone must grieve in the same way, (914) 835 - 8906 (914) 939 - 2878 Family members (especially children) or handle the situation the way they do, must be helped to see that their feelings otherwise they are cold hearted. That did not injure their family member. The person may have no real idea of what the other person's suicide is never caused by other person is going through. It may be them. impossible for them to realize that the “Search for Change has been rebuilding lives for more than Most of the time we feel responsible other person is truly different. They may 25 years and continues to be a major force that provides a for another's pain. This kind of discus- distance themselves from their family safe haven for individuals recovering from mental illness.” sion is heard frequently: member; at a time when the other person “If only we had done something dif- needs them greatly. ferently, this wouldn't have happened. In these cases it is good to focus upon We didn't do enough. I knew it all along, the ways in which one family member is but I was afraid to take a stand. We all different from the next, and has different Residential Services ways of handling their loss. This gives failed. It's as simple as that.” “Rebuilding lives Career Support Services everyone room to be themselves and Family members, friends and lovers and strengthening Private Case Management who are filled with unacknowledged have their own particular responses. So many of us are busy giving to oth- communities since 24 Hour Staff Support anger and self-blame often project these 1975.” feelings onto one another. They con- ers that which we ourselves truly would stantly find fault with everyone, and like to receive. We can't give it to our- create a difficult atmosphere. These indi- selves, but we can give it to another. 95 Church St., Suite 200 viduals simply must be helped to ac- Then we wait to get it back from them. White Plains, NY 10601 knowledge and accept their own feel- We may end up waiting a very long (914) 428-5600 fax: (914) 428-5642 ings. time. Or visit us on the web at www.searchforchange.com In such a case, we may greatly help When we can give to ourselves di- these individuals by telling them that rectly, it is much easier to see what the they are not to blame for what is going other truly needs and give it to them. on. It is surprising how much this may Giving Each Other Room to Grow The Center for Career Freedom calm them down. Of course they may A suicide in the family can destroy need to hear it over and over again. us, but it can also make us stronger and Computer Applications Training Sometimes this kind of opening will help wiser as well. There is a choice to be individuals express other feelings to you made. When we see other family mem- ● MS Office XP, Word, Excel, Outlook, PowerPoint & Access as well. Just listening to and accepting bers in a negative light after this, that is ● Keyboarding, Internet, QuickBooks, Photoshop their feelings will help relieve them of exactly how they will begin to feel self-blame and guilt. It is not necessary ● around us. The more negative the person GED Preparation to offer directives of any kind. Simply seems to us, the worse they will begin to ● Individual & Small Classes by being able to see that others accept feel. It is as though our very perception them dissipates a lot of tension . and image of them were being transmit- ● NYS Department of Education Licensed Casting blame happens so often that it ted. We may be ignoring the part of the ● merits real examination. Often it grows individual that is healthy and strong. Microsoft Certified into a gnawing guilt that persists for The more attention you give one as- Call for Appointment: (914) 288-9763 years on end. The deep sense of not hav- pect, the more it blooms under your ing done enough, not having been able to eyes. When family members start to be- One East Post Road, White Plains, NY 10601 save a loved one, leads many widows to come www.freecenter.org die within a year of their husband's see Helping Families on page 58 MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 55

Gene from page 9 of the hSERT variant. The report is consid- ered the first to identify a coding mutation in within-gene modifications being important in a transporter linked to a psychiatric condi- each affected individual. This is also proba- tion. Researchers found that the I425V muta- bly the first report of a modification in a tion of hSERT increased the transport activ- transporter gene resulting in a gain rather ity of this protein, capturing more serotonin than a decrease in function,” said NIMH and most likely reducing effects at the re- Director Thomas Insel, M.D. ceiving neuron’s receptors, outperforming SERT allows neurons, platelets, and other the common transporter. The mutant mole- cells to accumulate the chemical neurotrans- cule was not regulated normally and did not mitter serotonin, which affects emotions and respond to cell signals that activate the com- drives. Neurons communicate by using mon form of the transporter. Gary Rudnick chemical messages like serotonin between and Fusun Kilic, Yale University School of cells. The transporter protein, by recycling Medicine, with Murphy at NIMH, conducted serotonin, regulates its concentration in a this research, which was funded by the gap, or synapse, and thus its effects on a Rockefeller Brothers Fund, the National receiving neuron’s receptor. Alliance for Research on Schizophrenia and Transporters are important sites for agents Depression, and the National Institute on that treat psychiatric disorders. Drugs that Drug Abuse (NIDA). reduce the binding of serotonin to transport- Participants in the study published in ers (selective serotonin reuptake inhibitors, Molecular Psychiatry were: Norio Ozaki, or SSRIs) treat mental disorders effectively. Fujita Health University School of Medicine, About half of patients with OCD are treated Toyoake, Aichi, Japan, whose early work on with SSRIs, but those with the hSERT gene the project was supported by awards from defect do not seem to respond to them, ac- the Intramural Programs of the National cording to the study. Institute of Alcohol Abuse and Alcoholism Any vulnerability to OCD from gene (NIAAA) and the NIMH; David Goldman, effects most likely interacts with events in NIAAA; Walter Kaye and Katherine Plotni- the environment like stresses, other factors cov, University of Pittsburgh Medical Center like gender, and treatments, Murphy said. By examining the serotonin transporter gene’s and Western Psychiatric Institute and Clinic; mutation and flawed regulation in individu- Benjamin Greenberg, Butler Hospital and als with OCD, the new research provides Brown University School of Medicine; Ja- insights on transporter function and on the akko Lappalainen, Yale University School of consequences of the variant, which may lead Medicine; and Gary Rudnick, Department of to tests to identify and treat mental illness. Pharmacology, Yale University School of A related study in the August 2003 Mo- Medicine; Dennis Murphy, NIMH Labora- lecular Pharmacology tested consequences tory of Clinical Science.

Parity from page 8 health plans – the Congressional Budget Office estimates that this legislation will ● discriminatory insurance coverage of result in premium increases of only .9% mental illness bankrupts families and -- costs that are far outweighed by lower places a tremendous burden on taxpay- absenteeism and higher productivity ers through suicide, homelessness and when mental illness is treated earlier, inappropriate “criminalization" of men- and 34 states have enacted parity laws tal illness, similar to S 486/HR 953, but even these laws offer no protection for workers and Family Service their families that receive coverage ● parity is affordable for employers and through self-insured ERISA plans. of

Smoking from page 9 physiological effects of such a reduction Westchester in MAO B in peripheral organs, we do The researchers observed that MAO B know we need the enzyme to break activity in the peripheral organs was down blood pressure-elevating chemical Strengthening Individuals, Families and Children reduced by one-third to almost one-half compounds in certain foods, as well as Since 1954 in smokers compared with nonsmokers. those that are released by nicotine. Thus,

The scientists caution that the effects it is possible that lower levels of this of this finding remain unknown at pre- enzyme in peripheral organs could have sent. "The consequences of reduced lev- medical consequences." Adoption & Children’s Services els of this important enzyme need to be Previous research by these scientists Big Brothers & Big Sisters examined in greater detail," explains Dr. has shown that the level of MAO B is Fowler. "Though we do not know the lower in the brains of smokers. Youth Services Family Mental Health ADAPT - A Different Approach For Parents & Teens Co-Occuring from page 36 the drug for such suicidal clients. "We at Camp Viva & Project Care F.E.G.S, of course, are particularly con- difficult. Also, coordination of care with cerned with the risk of suicide with our Home Based Services treating psychiatrists must always be at dually diagnosed clients" says Joyce Senior Personnel Employment Council the forefront." Kevelson. "By working with clients on My Second Home ~ Adult Day Program On the pharmacological side of the their substance abuse and mental illness equation, research suggest that clients issues simultaneously, we can educate EAP & Elder Care ~ Corporate Programs being treated with lithium for bipolar consumers and reduce the risk." disorder were only about one-eighth as likely to commit suicide as those not The factual materials in this article www.fsw.org taking the drug. However, lithium re- have been taken from: Harvard Mental quires regular blood tests to ensure its Health Letter, Vol. 19, Nos. 11 and 12, One Summit Avenue • White Plains • New York efficacy. Similarly, a recent study of May and June, 2003 - Confronting Sui- schizophrenic clients showed that cide I and II. and Integrated Treatment Clozapine reduced the number of suicide for Dual Disorders, A Guide to Effective attempts in that population as well. Con- Practice, K. Musser, et al, The Guilford 914-948-8004 sequently, the FDA has now proposed Press, New York, 2003, p. 8-9, 117-118. PAGE 56 MENTAL HEALTH NEWS ~ WINTER 2004

Lessons from page 22 worked, she hung herself with her shoe- Mind Thing from page 52 do not forget this picture so fast. laces. Again I think to myself, what is Not only did they see the amounts of anything that came her way, except de- your life like that you would even think Be sure to ask yourself if you are salt, fat and sugar they are consuming pression. I remember the first time she to do such a thing? So much pain. consuming a variety of foods. Do you but, the hands on activity very often was hospitalized since I had known her. My first thought was, how could she have at least two servings of lean meat, leaves a lasting impression. Working It was my first visit to an inpatient men- have done this over a guy? Again, stu- fish, poultry daily? Are you consuming with clients has taught me that most of tal health unit. I was scared, they buzzed pidity on my part. This had nothing to do the minimum of five fruits and vegeta- us need clear understanding of portion me in and I walked towards the desk as with him, it was about so much more. I bles a day? Do you have at least two control and how to gauge portions when the door locked behind me, unsure of then came to learn that she left letters in servings of dairy daily? Are you includ- we eat out-so we do not overeat and what I was supposed to do or what to her apartment before going into the hos- ing whole grain breads and cereals? sabotage our efforts. expect. I stood at the nurses station un- pital for important people in her life, Choosing whole wheat and whole grain The key to healthy eating is develop- noticed for several minutes and finally indicating to me that this had all been versions of breads and starches will help ing meal plans that help you achieve someone acknowledged my presence and carefully planned on her part. She was you meet daily dietary fiber require- good sensible eating behavior. Meeting said I had to sign in as they paged my so smart. She knew that if she was hos- ments. Most fruits and vegetables and with a registered dietitian (known as a friend to come to the desk. The person pitalized again, she would end up back at beans are good sources of dietary fiber. R.D.) to review what foods you like will that emerged to greet me was not my the state hospital, a place she never Soluble fiber binds bile acids and cho- ensure a skilled therapist to assist you friend but some other person that was in wanted to return to. People there told lesterol in the intestinal tract, preventing with meal planning and your own nutri- a seemingly drug-induced haze and her that all she would ever amount to their reabsorption. Increasing soluble tion concerns. An R.D. is an expert could barely speak. I was horrified! would be “a mental patient on the back fiber in the diet can help to reduce serum about portion control and can evaluate What had happened to this vivacious ward of some state hospital”. They cholesterol. The easiest way to do this is your food intake to ensure you are get- person? After a few weeks or days she couldn’t have been more wrong. Renee simply to eat more fruits and veggies. ting the vitamins and minerals needed. would rebound and return home and was so much more than that, she was a Raspberries are one of the richest source Lastly, the more you exercise the immediately back to work, a place where peer specialist, aiding other consumers in of fiber (one cup contains 40 grams) more you will enjoy it. It is a wonderful I believe she truly found joy. This vi- locating services and support. She was their fiber is in the tiny seeds. To be way to unwind. Think about walking on cious cycle of rehospitalization would the first peer to staff our peer bridging worthwhile as a fiber source, a cereal trails or the local track while catching up occur many times over the course of the program at our local hospital, aimed at should be at least 4 and preferably 5 with a friend or biking on a country next two years and I truly got a sense of reducing rehospitalizations through com- grams of bran per one ounce serving. road. When you become involved in the struggle for wellness, and the energy munity support. She was a mother to a As a registered dietitian, my experi- more regular activities, you’re more that is required to battle your own mind. son she loved more than anyone on the ence has taught me that many people prone to eat when you’re hungry instead In June of 1999 I was preparing to face of this beautiful earth. She was a gain weight not because they eat the of eating out of boredom or loneliness. vacation in Florida for a few days and daughter and a sister, and to me and wrong foods but because they tend to be Good food and the good feeling it en- once again, Renee was in a deep depres- many others, she was a friend, someone clueless about portion sizes. In sessions genders at the table is not only a delight sion, following several recent hospitali- who touched our lives in a very special with clients, I will use a can of Crisco but it is most necessary for our well be- zations and the fear of another. A few way with her smile, a hug, her delicious and bags of potato chips, cheese doo- ing. days before my departure, she gave me a cookies (we shared a love of baking) and dles, nachos etc. to instruct on the fat Let food be your medicine and medi- letter. It was a resignation letter, stating unconditional love and friendship. and salt content of their favorite foods. I cine be your food (Hippocrates). Using that when I returned from Florida she It took a long time for me to really will allow the client to try and give the your mind is the best way to trim your would no longer be working for our understand what her death meant. It amount of fat by using the Crisco for body. agency. I had suspicions about the meant peace. Peace from an illness that each of the food items. Most clients are For more information on registered meaning of this letter, was it a resigna- robbed her of opportunity, peace from amazed to find out how much fat, salt dietitians, visit the American Dietetic tion letter or something more? I talked memories of the past that haunted her and sugar are in their snack foods. Most Association at www.eatright.org. with her about it and she shared her de- waking and sleeping hours, peace from spondency with me over being lonely. the exhausting effort it took for her to She had recently moved into her own put a smile on her face and greet the cold apartment which most people would cruel world every day. Peace from try- think is a good thing but in her case, I ing to be what everyone thought she think not. She was also distraught over a should be instead of just being herself. love interest that was not reciprocating I learned a lot of hard lessons from her affection which I tried to minimize my short friendship with Renee. First, saying there were “other fish in the sea”. you cannot save people, they have to How stupid of me to minimize her feel- want to be saved. Second, what I want ings. I encouraged her to talk to her for others is not necessarily what is best therapist and doctor to perhaps try a for them, they need to make their own medication change. What I really wanted choices and live with the consequences. was for her to go back in the hospital Finally and most importantly, live every where I thought she would be safe. I day as if it is your last, tell everyone you didn’t realize at the time that there is no care about how you feel about them. Let safe place. them know how much they matter to you NAMI-FAMILYA of Rockland County She was admitted to the hospital the and what they give to the world, each of day before I left for Florida. I remember Rockland’s Voice on Mental Illness my sense of relief that I would not have us has something unique to offer. I re- to worry about her while I was away and member every time Renee would end a is pleased to announce that whatever was wrong would be re- conversation with me, she would always the opening of our new office at say, “love ya”. I know that she did and solved when I got back and we could talk about her coming back to work. I that was a comfort to me after she died, left for Florida, had a wonderful few and even still today. Rockland Psychiatric Center days away and when I got home I re- I am reminded every day through my Bldg. 57, Room C 102 (first floor) ceived a message from a professional work that many others are here strug- colleague asking me to call as soon as I gling with depression, addiction, anxiety, 140 Old Orangeburg Road got home. The message seemed a little bereavement and doing what they can to Orangeburg, New York 10962 strange, but I run a mental health agency. recover. They are an inspiration to me Perhaps something had occurred while I and remind me every day what is really was away that I needed to know before important. Renee’s picture is on my Telephone and Helpli ne (845) 359-8787 desk along with an angel. I consider her returning to work. What an understate- FAX (845) 359-8315 ment. That was the call. my guardian angel, reminding me that with hope all things are possible and that Email : [email protected] Renee had committed suicide while in the hospital and on a five minute watch. a friendship doesn’t have to be long to be How could this have happened?!! What deep. Of course I wish she were still Serving Families through Education, Support and Advocacy do you mean she’s dead?! I can’t be- here but she’s where she wanted to be, at lieve this is happening!! Of all the times peace finally and I am still here, with her affiliated with NAMI & NAMI-NYS – the National Alliance for the Mentally Ill she’s cut herself in the past, she’s always in my heart, sharing the gift of hope so survived, how could this have happened? that others might find peace and purpose Well, she tried something new and it here in this world. MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 57

Eastern from page 27 with a life partner for ten minutes, taking a hike, meditating, taking a hot bath, talking to some even say illusory. What thoughts and a professional counselor, taking proper medi- Mental Health Association feelings are permanent? How often do the “I cations, repeating affirmations, making or love you’s” of today, become the “I don’t listening to music, etc.) and choosing to prac- of Rockland County care for you’s” of tomorrow, only to become tice them daily. the “I like you’s” of a later time? “People When severe depression arises, with the change” is a way of understanding that, yet sometimes accompanying impulses to de- we often treat our own emotions as if they are stroy oneself, it is best to rely on the wellness permanent and unchanging. In fact, the very activities, which one has developed in the nature of depression is that the oppressive past. One does not knit a parachute as the thought/feeling states, which descend, appear plane is falling to the ground; the parachute is “Working For The Community’s Mental Health” to the person in the midst of the depression as better prepared over the course of time, so it if they are permanent: they have always been is available when needed. In a similar way, there, and will always be. This is what can the connections to others, nature, and one’s lead to a sense of hopelessness, when the own self which one can develop can serve truth is that these moods are anything but well in times of crisis. Nurture and acknowl- 845-639-7400 permanent. How can one remember this in edge the goodness within yourself, and you the midst of a depression? Talking to a friend can limit the pattern of suicidal thoughts 20 Squadron Boulevard . New City . NY or counselor can make a difference. Availing which may arise. The thoughts may still oneself of the support of help-lines, joining arise, but you may find you are able to limit visit us at: www.mharockland.org peer support groups, taking useful medica- their disruptive influence on your day. Like tion, and remembering the wellness supports in a meditation, you can acknowledge the in one’s life can all lead to a better pattern of presence of the thought, assess that you are choices than those of a depressive cycle. not bound to act upon it, and then move on. One way to control the downward depres- A depression that does not lead to suicide can sive spiral is to get some distance from the often be a spur to one’s growth, and a bless- emotions you are experiencing. This is ex- ing in disguise. Just as there are knee-jerk pressed in the statement, “Have your feel- reactions, there can be “psyche-jerk reac- ings, don’t become them.” Emotions arise tions”; we may find ourselves reacting in and subside, find some solace in the pauses habitual ways to stressors. These can include between the ebb and flow. “The difference thoughts of worthlessness, hopelessness, between despair and hope is often a good despair, embarrassment; many things can be night’s sleep.” This quote adequately summa- triggers. When we notice we are in the midst rizes the nature of emotions: transitory, sub- of a psyche jerk reaction, we can simply ject to change, yet seemingly so entrenched choose from a previously developed list of and real when they are being experienced, wellness tools such as following the breath, particularly when one is in the midst of any talking to a friend, journaling, taking a walk. strong emotional reaction, such as a depres- The wisdom of the East has been helpful sion (or great success, or falling in love, for to many in learning to cope with life’s most that matter.) Recognizing that one is de- difficult moment. To be able to stay in the pressed is the first step to unraveling the moment is a great gift, in that it allows the pattern. The simple statement “I am de- hope for one to relax and accept what comes pressed” reflects the emotional distance that one’s way with an easy heart. Some yogis allows one to understand the temporary na- describe an attainable state in which honor ture of the depressing thoughts and feelings. and shame, joy or sadness, fortune or poverty It implies a future when one may not be de- can all be accepted from a state of grace. For pressed any longer. No depression is perma- most of us, this seems like an unattainable nent, even though it can seem that way in the ideal, sometimes we just want to get through midst of one. In Steel Magnolias, Shirley the day. We can always take some refuge in Maclaine says “I’ve just been in a bad relaxing into the present moment no matter mood…..for 39 years.” Although we may what the occurrence. Think you’re doing sometimes feel like this is the case, in any well? Relax while following your breath. day good moments occur. Recognize them Think you’re doing terribly? Relax by fol- for what they are: a smile offered or received, lowing your breath. In this way, we can pre- a kind word, a moment to pause and look at pare for all the moments of life, and prevent nature. Accentuating the positive, acknowl- the winds of life from blowing us over. Opportunities to Heal Grow and Recover edging its existence is a powerful measure to We are all going to die one day, and this cope with negativity. Some teach that one nature of preparation (remaining in the mo- should repeat affirmations such as “The light ment, relaxed in one’s breath) can be very Putnam Family & Community Services is: of love is within me” even when one feels useful at moments of extreme transition, of quite the opposite. Words can be powerful in which death is the ultimate. Many of the and of themselves. Welcoming Accessible The best way to deal with suicidal feelings earth’s people believe in reincarnation. In the Offering professional treatment Open Mon-Thurs 8am-9pm is to cut them at the root, the root being the face of that belief, suicide makes no sense in a healing environment Fri. 8am-6pm - Sat 9am-5pm negative thought/feeling/action patterns whatsoever: one will simply have to return, which feed the depression. (Of course, if one again and again, to deal with the feelings and is feeling like one is capable of hurting one- issues which one was trying to escape from. Affordable Caring self, or another, and liable to, the best course Even if one does not believe in a life after PFCS does not deny treatment to Our services treat of action is to seek professional help.) But, this one, suicide makes no sense whatsoever. anyone because of inability to pay each person as a whole prior to arriving at the extreme state of con- A Creator put us here certainly for a different templating, planning, and deliberately arrang- purpose than to put an end to pain. The na- ing things such that one could carry out an Comprehensive ture of pain can be such that it leads to a feel- attempt on one’s life, the best course of ac- tion is to establish a daily practice of well- ing that it will be endless; the yogic practice Prevention, treatment, rehabilitation and self help including: ness. “How do you get to Carnegie Hall?” of being in the moment frees one up from too Mental health and chemical dependency counseling for all ages “Practice, practice, practice.” much attachment to any particular moment. Psychiatric evaluations and medication management You feel one way this moment, don’t get too “How do you get to a state of wellness?” Crisis Intervention “Practice, practice, practice.” Remembering happy about it: it will pass. You feel another that high and low feelings, euphoria and de- way the next moment, don’t get too upset Recovery and rehabilitation through Continuing Day Treatment pression are transitory, one can practice ac- about it: this will pass, too. Pay attention to Advocacy and linkage through Case Management tivities that support wellness and a reduction the breath, let that attention be a vehicle to of symptoms. Mary Ellen Copeland’s Well- carry you across the waves of samsara. De- ness Recovery Action Plan is an extremely velop your wellness recovery plan, practice 1808 Route Six Carmel, New York effective tool. The WRAP plan is particularly wellness, and see the best in yourself and effective in enhancing one’s wellness (www.mentalhealthrecovery.com). The es- others. Remember that every moment has its sence of this plan is to spend some time iden- successor, that all things must pass. In this tifying and listing activities which support way, one can move towards living a more (845) 225-2700 wellness, (e.g., talking to a friend, connecting positive life. PAGE 58 MENTAL HEALTH NEWS ~ WINTER 2004 Read This from page 15 2) Give yourself some distance. Say to • Send an anonymous e-mail to The yourself, “I will wait 24 hours before I Samaritans (http:// greatly in their capacity to withstand do anything.” Or a week. Remember that www.befrienders.org/talk.htm) pain. When pain exceeds pain-coping feelings and actions are two different • Call 1-800-SUICIDE in the U.S. resources, suicidal feelings are the result. things - just because you feel like killing Suicide is neither wrong nor right; it is yourself, doesn’t mean that you have to • Teenagers, call Covenant House not a defect of character; it is morally actually do it right this minute. Put some NineLine, 1-800-999-9999 neutral. It is simply an imbalance of pain distance between your suicidal feelings versus coping resources. and suicidal action. Even if it’s just 24 • Look in the front of your phone book for a crisis line hours. You have already done it for 5 minutes, just by reading this page. You • Call a psychotherapist can do it for another 5 minutes by con- tinuing to read this page. Keep going, • Carefully choose a friend or a minis- and realize that while you still feel suici- ter or rabbi, someone who is likely dal, you are not, at this moment, acting to listen on it. That is very encouraging to me, Now, while this page may have given and I hope it is to you. But don’t give yourself the additional you some small relief, the best coping burden of trying to deal with this alone. resource we can give you is another hu- 3) People often turn to suicide because Just talking about how you got to where man being to talk with. If you find some- they are seeking relief from pain. Re- you are, releases an awful lot of the pres- one who wants to listen, and tell them member that relief is a feeling. And you sure, and it might be just the additional how you are feeling and how you got to have to be alive to feel it. You will not coping resource you need to regain your this point, you will have increased your feel the relief you so desperately seek, if balance. coping resources by one. Hopefully the you are dead. Suicidal feelings are, in and of them- first person you choose won’t be the last. selves, traumatic. After they subside, 4) Some people will react badly to your There are a lot of people out there who you need to continue caring for yourself. really want to hear from you. It’s time to suicidal feelings, either because they are Therapy is a really good idea. So are the You can survive suicidal feelings if frightened, or angry; they may actually start looking around for one of them. various self-help groups available both you do either of two things: (1) find a increase your pain instead of helping way to reduce your pain, or (2) find a in your community and on the Internet. Now: I’d like you to call someone. you, despite their intentions, by saying way to increase your coping resources. Well, it’s been a few minutes and you’re or doing thoughtless things. You have to still with me. I’m really glad. Both are possible. understand that their bad reactions are Since you have made it this far, you "Reprinted with permission. From the about their fears, not about you. deserve a reward. I think you should website, Suicide: Read This First (http:// Now I want to tell you 5) But there are people out there who www.metanoia.org/suicide) was written Five things to think about. reward yourself by giving yourself a gift. can be with you in this horrible time, and The gift you will give yourself is a cop- by Martha Ainsworth based on work by 1) You need to hear that people do get will not judge you, or argue with you, or ing resource. Remember, back up near David Conroy, Ph.D. To talk with a car- through this -- even people who feel as send you to a hospital, or try to talk you the top of the page, I said that the idea is ing listener about your suicidal feelings, badly as you are feeling now. Statisti- out of how badly you feel. They will to make sure you have more coping re- in the U.S. call 1-800-SUICIDE any cally, there is a very good chance that simply care for you. Find one of them. sources than you have pain. So let’s give time, day or night. Online, send an you are going to live. I hope that this Now. Use your 24 hours, or your week, you another coping resource, or two, or anonymous e-mail to [email protected] information gives you some sense of and tell someone what’s going on with ten...! until they outnumber your sources for confidential and non-judgmental hope. you. It is okay to ask for help. Try: help, or visit www.befrienders.org." of pain.

NARSAD from page 20 NARSAD has funded nearly $3 million Helping Families from page 54 now. Write them down. Share them in research to help find the causes and with your friend. men attempt suicide, men are more than cures for the severe mental illnesses well again, often it is because they be- • Find five positive things about the four times more likely than women to which lead people to feel that suicide is come in touch with their natural desire situation you both are presently in. actually kill themselves. There is some their only option. to live and thrive. Just like sap in the Write them down. Share these, too. NARSAD-funded researchers have trees, this healing force can rise in eve- evidence that this difference stems from the methods men and women use. investigated many different aspects of ryone. Seeing With Love Women are more likely to take pills and suicide including: the chemi- By relating to that which is life-

to slit their wrists, actions that are not cal/biological causes of suicide; the ef- giving, you encourage the healing force Seeing with love means relating to fect of hormones in suicidality; how to grow. immediately fatal and can be thwarted if another person’s strong points. This medical help is received in time. Men, early detection and intervention (with We must always be conscious of the strengthens, enables and sets them free. on the other hand, are more likely to medication and talk therapy) in patients kind of image we are projecting onto a Seeing with love respects another's with severe mental illness may prevent given person, particularly someone who shoot themselves or jump from a high choices. Dependency holds a person too building. suicide; identifying behaviors that may is grieving. Your view of the other is closely and causes weakness in many indicate suicidality; the biological differ- always being communicated whether ways. How to Help a Suicidal Loved One ences between adults and adolescents you want it to be or not. Can you look A good way to know if we are seeing Know the warning signs! who exhibit suicidal behaviors; psycho- through the eyes of strength and love? with love and encouraging another is to social risk factors for teenage suicide; How you choose to perceive him is up to Most suicidal people give clues about look at the effects our behavior is having the relationship between poor sleep you. You can choose to see his courage, their feelings. Don’t be afraid to ask upon the individual. Do they bloom a quality and suicidal ideation; the effect aliveness and ability to love rather than someone you are worried about if he or little around us? of medications prescribed to treat mental his weak spots. she is thinking of taking his or her own It is also important to always ask illness on suicidality; why some people The way in which you persistently life. You cannot make someone suicidal ourselves if we are giving to another in with major depression commit suicide choose to see another person will also by asking a direct, caring question. Tell order to hold them or to help them grow. and others do not; and the effect of sub- inevitably effect how you see yourself. your loved one that you are worried and When we truly love another, we also stance abuse on suicide rates. give specific reasons why. Stress that he feel loved and complete. There is noth- NARSAD is committed to funding Process or she is very important to you and to ing the person has to do to earn or de- these and future studies to provide hope other people. Encourage that person to • Write down your description of the serve our love. We love and respect the for those suffering from severe mental get help through a psychiatrist, social family members. person just because they exist. This is illnesses. To learn more about NAR- worker, clergy member, or other mental the very best healing and cure for grief, SAD, please visit us at www.narsad.org. • List whatever adjectives come to health professionals. loss and anguish of all kinds. your mind. Are you focusing on

their weaknesses or their strengths? How NARSAD is Helping Constance E. Lieber is the President • Find five beautiful things about Dr. Brenda Shoshanna is an author Since 1990, the National Alliance for of NARSAD (the National Alliance for each person exactly as they are and psychologist in practice in Manhat- Research on Schizophrenia and Depres- Research on Schizophrenia and Depres- now. Write them down. Share them tan. You can visit her website at sion (NARSAD) has awarded 38 sepa- sion). She is a frequent contributor to with him. www.brendashoshanna.com, e-mail at rate grants to medical researchers who Mental Health News, and serves on its • Find five beautiful things about [email protected], or by phone at are investigating the causes of suicide. Advisory Council. yourself, just exactly as you are 1-866-656-8337. MENTAL HEALTH NEWS ~ WINTER 2004 PAGE 59 Subscribe Advertise

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