At first blush the case of Esmin Green, a Jamaican immigrant who died unattended on the floor of a Brooklyn psychiatric emergency room, is outrageous. She’d been left in a chair in a waiting-room for 24 hours before falling off that chair and dying. It hardly seems possible that a patient requiring hospitalization would have been left to languish that way, in the 21st century and in the United State of America. This is, after all, not some third-world country with only a few working hospitals and insufficient facilities.

But as outrageous as this case is … it turns out that it is not at all uncommon for psychiatric patients to be left for 24 hours — sometimes, for many days on end! — sitting in waiting-room chairs:

The unit [in which Green was left to die] is so routinely backed up with people waiting hours, or even days, for services that patients often spend the night nodding in chairs or sprawled in a corner. …

A survey of hundreds of U.S. hospitals released last month by the American College of Emergency Physicians found that 79 percent reported that they routinely “boarded” psychiatric patients in their waiting rooms for at least some period of time because of the unavailability of immediate services.

One-third reported that those stays averaged at least eight hours, and 6 percent said they had average waits of more than 24 hours for the next step in a patient’s care. …

Emergency physicians at other hospitals describe conditions far less grim, but they uniformly agreed that a hospital waiting room is rarely a comfortable place for someone in a psychological crisis.

“Optimally, you don’t want a patient sitting in the emergency room for any length of time,” said Dr. Bruce Schwartz, the director of clinical psychiatry at Montefiore Medical Center, in the Bronx.

Still, those types of waits can be routine.

In Austin, Texas, hospital officials have complained that a county decision to reduce the number of patients sent to a state psychiatric hospital has clogged their emergency rooms with mentally ill people with no place else to go.

In Massachusetts, some parents have complained about days-long waits in the emergency room for children who need placement in a pediatric psychiatric service.

California health officials have struggled for years with complaints about overcrowding in psychiatric emergency rooms.

I can attest to this phenomenon personally: I was once forced to spend 18 hours in an ER because I happened to arrive a few minutes after the crisis worker left (there are none available in my area, any more, except during “bankers’ hours” on weekdays), and had to get my “PC” (psychiatric consult) once she came in the next morning and only after higher-priority patients had been PC’d (as a depression patient, I didn’t rate very highly). This was in a small community hospital in the suburbs, not a massive, bustling, bursting-at-the-seams urban healthcare center like Kings County.

Note that this rule applies generally only to psychiatric patients. If someone were to arrive in an emergency room due to, say, a car accident or a heart attack, a regular hospital bed would be found relatively soon; no accident or heart-attack victim would be left sitting for days in an ER waiting-room. Yet, this is considered acceptable and even routine, for psychiatric patients. Why is this? We still have not gotten over the fact that mental illnesses are real, they deserve to be treated, and that the mentally ill are human beings entitled to the same dignity and compassion that anyone else with some other malady would be given. This simply cannot be tolerated any longer.

The headline of this ABC News report says it all: “Ignored Psych Patient Dies on Hospital Floor.” Most people go to the hospital to get help, not to be allowed to fall on the floor and left to die … despite having security guards — and even a doctor! — notice them before walking away!

Note that this poor woman had been sitting in that waiting room — it wasn’t even a treatment room! — for some 24 hours by the time she fell on the floor. That’s right, they had been ignoring her for an entire day! (A video report from NBC’s Today is embedded below; the raw video is available from ABC News.)
New York Hospital patient ignored to death! - Videos are here

I have no doubt that everyone involved in this case chose to ignore her, because she was a “psych patient” who’d been reported as having been “agitated,” and whom they simply did not wish to deal with.

They got their wish — she will, in fact, never bother them again — but hopefully the authorities will not let go and will remind them of it as much as possible.

The treatment of the mentally ill in the US, especially in urban hospitals like Kings County Hospital but also in others around the country, is simply dreadful. Psych patients are considered burdens rather than people with ailments who need help, real help.

We simply must stop viewing psychiatric ailments as “eccentricity” or as “bothersome.” We have seen in this case (and likely in others that haven’t happened to be so well documented) that ignoring psych patients kills them. We can no longer afford the luxury of being casual about mental illness, or denying its existence (as the anti-psychiatry movement does).

Folks, do not forget poor Esmin Green, who died alone and ignored on the floor of a hospital in plain view of many people. Do not let it happen again, to anyone, ever. Stop treating the mentally ill as disposable. It must STOP, and it must stop NOW!

Over the last two weeks there have been a number of shooting-sprees across the US. The most recent was at Northern Illinois University. It turns out the shooter had been in treatment for a mental disorder:

University Police Chief Donald Grady said Friday that Kazmierczak had become erratic in the past two weeks after he stopped taking his medication.

This article adds a couple of points about this shooter:

A former employee at a Chicago psychiatric treatment center said Kazmierczak’s parents placed him there after high school. She said he used to cut himself, and had resisted taking his medications. …
“He never wanted to identify with being mentally ill,” she said. “That was part of the problem.”

There’s probably no one who knows better than I, the desire to deny the reality of mental illness. I also have had my own battles with medication; having taken at least one of all the major varieties of psychotropic medication, I’ve experienced them first-hand and understand the desire not to take them. Really. I get it. I’ve been there.

But the truth is, folks, that none of us lives in a vacuum! We’re all responsible for our part in the lives of others. No one benefits when a mentally-ill person terminates his/her treatment; everyone else in his/her life must pick up the slack and deal with the results of that decision. Denial of the reality of mental illness has repurcussions throughout one’s life. In this case, denial killed (not only the patient, but 5 others, and wounded more). Even in cases nowhere near this extreme, there is nevertheless a price to denying mental illness; interpersonal problems, inability to keep a job or take care of oneself, and so on. A mentally-ill person who refuses treatment for his/her disorder automatically places a burden on others.

The lesson here is a simple one: No one who’s on notice as having a mental illness, can afford the luxury of acting as if that illness doesn’t exist. You have to stick with your treatment, whatever that is, no matter what. If the treatment is not helping or not to your liking, then change it … but don’t decide not to pursue any treatment at all.

Perhaps this isn’t fair … after all, neither I nor anyone else with a mental illness asked for it, so why should any of us be saddled with this responsibility? But we all know that life is not fair. Lots of people have lots of illnesses and problems that they must deal with nevertheless. Looking for fairness in life, is a fool’s errand; you aren’t going to get it. So rather than obsess over fairness, obsess instead with making the best of one’s life. This means taking responsibility for one’s condition and treating it.

It’s a scandal! Of course antidepressants don’t work, and their makers know it! Now we have proof!

… uh, guess again, folks … the real story here isn’t entirely what you may think it is. Here’s a sample story on this revelation (this one from the New York Times):

The makers of antidepressants like Prozac and Paxil never published the results of about a third of the drug trials that they conducted to win government approval, misleading doctors and consumers about the drugs’ true effectiveness, a new analysis has found.

OK, so what we have here is not a grand exposé on the utter failure of antidepressants … what we have found out, rather, is that drug companies tend to publish clinical trial results favorable to their drug.

If this surprises you, why should it? Of course companies are going to publicize what’s in their best interest to publicize! FDA review of drug efficacy generally includes even those studies whose results aren’t favorable and may not have been published, so from a regulatory point of view, this is not a problem at all.

Now, I’m already on record as saying that the widely-touted 60% efficacy of antidepressants — which is supported by a majority of studies and therefore a sound conclusion — is not sufficient; that 60% efficacy of anything would not be acceptable in most other areas of life.

But come on, people, let’s not blow this out of proportion! We haven’t exactly discovered anything new here. In fact, I suspect this is really “invented” news, extracted as it is from information made public over the last couple of years. If this is the worst news they could find, after poring through this new information for that long a time, then let’s face it, it’s not that bad!

The cold hard fact is that antidepressants work for many people. The last thing we need is yet another mass-media blitz being plastered all over the country which tells people that they don’t work. Too many mood-disorder sufferers already get no treatment at all, convinced that nothing can help them … to add to their number, this way, is a travesty.

As I do most days I just did a Google News search on “bipolar disorder.” I noticed that most of the top-listed stories were about Britney Spears and her latest pathetic publicity stunt; I didn’t actually read the stories but from the headlines I surmise that rumor has it she’s bipolar.

My first thought was, “Whew! That’s all we bipolar folks need, to be associated in the public eye with that ridiculous tramp.” This won’t help at all.

My second thought was, “With all of the research going on into bipolar disorder, somehow stories about that tramp — who may or may not even have bipolar disorder — drift to the top of the list?” The mass media have nothing more constructive or meaningful to report, on the topic, than that? That by itself should be enough to depress anyone … !

I hadn’t spent more than a couple months in the world of psychiatry, before I realized that having more than one diagnosis was common. But a recent news item actually backs up this intuition with hard data:

A new study discovers a majority of psychiatry outpatients have more than one disorder, and more than one-third have at least three disorders. Researchers found major depression as the most common diagnosis followed by social phobia….

Most patients had more than one diagnosis; on average, patients had 1.9 current diagnoses. Patients with principal diagnoses of posttraumatic stress disorder (PTSD) and bipolar disorder had the highest number of diagnoses.

This is significant for a number of reasons, one of which the story points out:

Most treatment studies exclude patients with multiple disorders. The authors said, “We hope that by documenting the high frequency of comorbidity in clinical practice, this will provide the impetus for modifying how treatment studies are conducted to allow patients with multiple disorders to be included and to determine the outcome of comorbid disorders as well as the primary disorder that is being treated.”

What makes this consideration compelling is because clinical trials are often a way for patients with severe problems — which have not successfully been dealt with — to find additional treatment venues; but most these people who so need new treatments, are automatically disqualified, since they have more than one diagnosis.

Comorbidity is not really all that new; in fact, the current DSM-IV uses a multi-axial system, wherein personality disorders have been shunted into their own “slot” if you will (called Axis II). What this study shows is that there is a lot of comorbidity among what are Axis I disorders.

It’s nice to see my own intuition confirmed; it will be another thing entirely to see what psychiatry does with this information. Perhaps the current diagnosis system should be rethought, taking this tendency into account? They’re years away, yet, from releasing the DSM-V; perhaps it’s time to account for comorbidity in a more comprehensive way?

I came across a review at Slate, the online magazine, of a book on ECT, commonly referred to as “shock therapy.” It offered a view of ECT that one rarely sees anywhere else in the media; namely that it’s a powerful treatment for mood disorders, and that the visions of it that Hollywood has conjured up over the last few decades, don’t represent the facts.

Now … I find this refreshing because — while I have never had ECT myself — I do know several people who have. Almost without exception, they found it helpful (if not the most pleasant experience), and most would do it again if they had to. This information almost totally contradicts everything else I’ve ever heard about ECT … i.e. that it’s a drastic treatment, has horrible side effects, it’s only used as a treatment of last resort, has injured people, etc.

Am I saying this book, and the Slate author who reviewed it, are right? No. I am, however, saying that perhaps the common fear of ECT is overblown, and maybe … just maybe … there are mood-disorder patients who could benefit from it, who will never get it, because 1) they are afraid of it and refuse to entertain it as a possibility; 2) people around them are afraid and tell them not to; and/or 3) their doctor is afraid to recommend it.

In other words … it’s something to consider. Something that — perhaps — we ought not be so quick to dismiss.

By now you’ve heard about the Omaha mall shooting; the perpetrator was said to have been depressed. The result of this is that people will associate atrocities like this, with depression … but without reason. The fact is that people with depression are no more or less violent than anyone else. In some cases, depression can be so disabling as to prevent someone who might choose to do such a thing, from trying it.

Since this shooting we’ve been treated to innumerable media stories on this troubled youth. And troubled, he was — clearly. His depression is evident in his suicide note(s).

The pertinent question here (here, being my mood-disorders blog!) is: Did his depression make him do what he did?

The answer is, no. In addition to being depressed, the shooter was also obviously sociopathic; he had a juvenile-criminal record. His sociopathy had far more to do with this than his depression.

If depression alone were sufficient to cause people to become murderously violent, such shooting sprees would be far more common than they are, because millions of people in the US, at any given time, experience depression. Plainly, then, there is no direct causal link between murderous violence and depression.

The danger in cases like this, is not in depression itself; it’s in the combination of depression and sociopathy. And sociopathy is likely the greater motivator here (and in most of the other similar cases). Without the sociopathy, the shooter would likely have been just another depressed, isolated loner. (Tragic, to be sure, since no one should be a depressed, isolated loner … but such people are no danger to others.)

That the shooter had been a ward of the state for years, and in and out of various treatment programs, underscores this point: While depression can be treated, sociopathy is more or less untreatable. Its presence makes any kind of treatment virtually impossible — sociopaths devalue other people, which includes mental-health professionals, so that no one could penetrate the shooter’s own “internal world.”

So what lesson is there, here? As far as depression and people who suffer from mood disorders, there is none … since mood disorders are not correlated to such violence. The lesson lies in separating depression from other factors in people’s lives, to find deeper, underlying causes for problems. In the case of the Omaha shooter, the deeper problem was his sociopathy. While he may also have suffered from depression, in addition to being a sociopath, that was just a minor complication by comparison.

With the holidays upon us, the mass media give us obligatory stories about depression and the holidays. This is both good and bad … it brings to people’s minds an important topic, but as with so much the mass media do, it can also propagate misinformation. This year, it seems the record is being corrected, which is good.

In the past it’s often been said that depression is worse around the holidays, so much so that suicide is more common than at other times of the year. It turns out this is not actually the case! Read on for the clarification:

Most people have heard the bit of folk wisdom about how depression and suicide increase during the last two months of the year. The holidays can be stressful, no doubt about it: the crowds, the hassles, the cold weather, those annoying relatives you thankfully see only once a year.

And, of course, there’s seasonal affective disorder, perhaps better known by its apt acronym SAD. SAD is a mood disorder that strikes some people during the winter months, causing them to become depressed or lethargic. The disorder is not fully understood but thought to be caused by the decrease in sunlight during winter months.

While stress levels may increase, do suicide rates? After all, there are plenty of stressors throughout the rest of the year as well.

Actually there’s no evidence that suicide rates spike in December; in fact they drop slightly.

A 1987 study by researchers David P. Phillips and John S. Wills found that about 100 fewer suicides occur on holidays than other days of the year. Part of the reason may be that while holidays are stressful, they are also a time when friends and family come together, offering emotional and social support to troubled individuals.

Yep, this is a 1987 study. It turns out that it’s been confirmed by many others, since then. Snopes has a page devoted to this myth, as well. (This leaves me to ask why the myth of “depressed-holidays” has been allowed to persist for 20 years longer than necessary … but I digress.)

Another story reveals an additional, interesting fact:

While depression does occur during the holidays, local authorities agree they see a spike in depression just after the holidays, primarily in January and February.

Dr. William Kennedy, a psychologist and special deputy with the Clinton County Sheriff’s Office and a member of the hostage negotiation team for the Wilmington Police Department, said people have high levels of anxiety during the holidays and just prior to the holidays, but most depression occurs when holiday celebrations are over.

“I think a couple of things happen just after the holidays,” Kennedy said. “One is, prior to the holidays and as the holidays are going on, people tend to have more connections. They tend to talk to more people, friends and family members. Just after the holidays, that tends to decrease.”

When people talk about depression, usually they’re talking about a depressed mood. People saying, I feel down or I’ve got the blues, he said. “When you see those types of symptoms last more than a couple of weeks and they’re there most of the time, and when you see other associated features — difficulty with sleep, decreases or increases in appetite, changes and lowering of motivation — then you start to think about clinical depression. That’s what you see an increase in just after the holidays,” Kennedy said.

So it turns out that it’s not exactly the holidays that make people depressed, it’s the post-holiday crash that does it.

Knowing this, perhaps people can plan in advance. Perhaps have a get-together or party or something in the middle of January … ?

Canada recently began a deep analysis of its mental healthcare system (something the US desperately needs to do, too, but won’t, because the mentally-ill are not a political constituency that anyone in American politics cares about).

Some findings are now coming out, as a result, and they are interesting. The most notable finding is the relatively (and unexpectedly) high number of Canadian workers who reported having been diagnosed with depression. But something buried in this report is actually more significant:

In the past year, one in five workers took days off due to depression, anxiety or stress. More than half were off work for more than a week, and 20 per cent for a month or more.

That is an awful lot of lost workplace time. That time takes a toll not only on the affected worker, but on co-workers (who must compensate for the person’s absence) and the business itself. As most of us know, depression doesn’t just hurt the patient; it affects everyone around him/her, and the workplace is not exempt from this. Unfortunately, too many workers either don’t get treatment, or settle for inadequate treatment, fearing discovery of their “secret.” Their livelihoods are at stake so they tend to be overcautious.

If society would simply accept the reality of depression, a lot of misery — for those who suffer from it, and those around them, as well as the businesses they work for — could be avoided.