Psychological Implications of the Connecticut School Shooting

A lone gunman killed 20 children and 6 adults including himself at a Connecticut) School He used guns registered to his mother. The emergence of ASD and PTSD Acute Stress Disorder and/ Post Traumatic Stress Disorder) were identified as happening after a major incident such as this one. The symptoms that can be present in this situation were reviewed as well as some possible long term effects. The grieving process was also discussed. In the aftermath of such situations, attention is often focused on people with mental illness who might have the potential do do violence and/or commit a copycat crime even though in retrospect this is very small proportion of the population.The gun control issue and related psychological factors were also discussed.

I am writing this blog one day after the horrific massacre at a school in Newtown, Connecticut. Thus far it is known that a 24 year old man shot and killed his mother and then took three weapons including automatic assault rifle, dressed in combat gear and  appeared at the school where his mother taught. He was recognized as the son of a teacher and was buzzed in. He then killed 4 adults including the principle who had recently  instigated stricter security measures at the school and 20 students between the ages of 6 and 10 as well as himself. There was one report that he had some kind of argument at the school the day before the shooting. There are also descriptions that he was a troubled kid in school who had no friends and was very shy. He was said to be very bright in math. It was suggested that  he may have had Asperger’s Syndrome and was on the Autism Spectrum. Another report said that he spoke of demons and therefore suggesting he may have been paranoid with schizophrenia. His parents were divorced after 17 years of marriage and his mother was reported as very protective. He has a brother at college.

I have no idea of his diagnosis and would not make any attempt to speculate on on the nature of his mental condition.

Psychological Trauma 

Common wisdom and research in this area tell us  that the closer a person is to the traumatic event,  the more likely and the more severe the psychological trauma will be. This however is a complicated issue. Certainly the adults and children who witnessed the shooting (including of course anyone wounded ) would be directly effected.  This would include anyone in the school  who heard sounds and participated in the terror of hiding and escaping from danger.

The two conditions that will emerge from such an incident  are  Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder(PTSD) . According to the Diagnostic Manual of the American Psychiatric Association (DSM IV), the necessary requirement for both of these conditions must include the following :

The person has been exposed to a traumatic event in which both of the following were present.

1-The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.

2- The person’s response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behavior.)

In addition for us to make a diagnosis of ASD there needs to be three or more  symptoms such as  numbing, detachment, absence of emotional responsiveness or reduction in awareness of his or her surroundings (being in a daze) or derealization ( things don’t seem real) or depersonalization ( you don’t feel like yourself) , a tendency to re-experience the event by flashbacks, an avoidance phenomena related to recollection of the traumatic event, impairment of social and other areas of functioning, increased  anxiety and arousal with sleep and concentration problems and a duration of these symptoms  2 to 4 weeks.

In order for us to make diagnosis of PTSD  there needs to be similar symptoms as ASD with one or more symptoms of recurrent and intrusive recollections (manifested in young children by repetitive play), recurrent dreams, re-experiencing the traumatic event with illusions , hallucinations and flashbacks , physiological reactions, , persistent avoidance of stimuli associated with the trauma, numbing , efforts to avoid thoughts and feelings related to trauma, decreased interest or estrangement, inability to have loving feelings, insomnia, outbursts of anger , exaggerated startle response  impairment in social functions, with a t least one of these symptoms lasting more than one month.

For more detailed and exact definitions see the DSM IV (or the new DSM V which may be somewhat revised )

Trauma Not Limited to Immediate Geographic  Area

The development of these symptoms is not limited to people in the immediate vicinity.

Classmates who didn’t attend school that day can have symptoms as can people all over the world who are traumatized by accounts in the media which vividly reconstruct the events and allow others to identify with the victims. There will be very few school age children in the U.S. who will not have heard about the details of this event

I recall at the time of the Challenger disaster, we saw school children all over the country effected by seeing this spacecraft carrying the astronauts and some teachers disintegrate before their eyes on television . Similar situations have happened in other tragedies, which are covered, on TV.

Long Term Effects

It should be recognized that the acute and  long term psychological  effects of this trauma  goes beyond the two disorders described above The experience also  becomes woven in the psychological makeup of people who are impacted by it whether near or far where it happened . For some, the innocence of childhood is taken away . The sense of security is changed forever. Long after the acute symptoms are gone, the effects of this event will have changed the individuals who experienced it. In some cases it will be a determining factor in how they will mold their future lives. Perhaps they will always be a cautious person, looking for unexpected danger. In other ways, the trauma can motivate persons to become doctors, nurses, police, researchers or influence the way they view their own lives for better or worse.

The Need for Immediate Psychological Intervention;

There has immediately been an outpouring of offers of psychological help.

I am sure the school system ,local and state agencies  will bring in counselors and therapists. Local mental health professionals  will ofter their help. I know the Committee on Disasters of the American Psychiatric Association ( of which I have been a member ) has offered the local Psychiatric Society materials and information that can be useful . There has been offers from International Groups that have experience  with these situations as well as from the Red Cross and from the nearby Yale Child Study Group. There will be individual and group meeting with the teachers and counselors as well with parents and of course with the children. The teachers will be trained how to be sensitive to the reactions of the children. It is important that all involved be aware of the various symptoms that can develop after events like this (some of which were described above) Danger signals need to be picked up. I am sure a wide variety of techniques will be used for one to one therapy  as well as in groups. Talking in groups can be useful for many but for others individual sessions can be very helpful  or a combination can  be used. For some of the children, the comfort of discussions and interactions with their parents will be  most important. Some parents will know how to handle this, other parents will benefit by discussion or counseling. I don’t believe there is one method which needs to be applied. The techniques used in individual and group treatment can cover a wide range from catharsis which involves expressing  one’s experience and feelings, Cognitive Behaviors Therapy ( CBT) which uses correcting misconceptions  and directly dealing with ideas and behavior and  psychodynamic therapy  where underlying meaning is explored and interpreted. In some acute situations medication (anti-anxiety or other stronger tranquilizers  can be used and when conditions  such as major depression is identified, antidepressants may be prescribed.  Other techniques and combinations of approaches will be used especially the human support and caring offered by people near and far and by such groups as the Red Cross which will be quite useful and meaningful.

Grieving the Loss of Life.

As most of us know grieving is a very intense process. Kubler-Ross described five stages of grief ; denial,, bargaining , anger , depression and acceptance. However, when there is unexpected death, traumatic death especially by murder and death of children, the grief takes on a different pattern which has been labeled Complicated Grief. We can expect the anger and depression to be greatly intensified and the duration of the intense emotions to be much more prolonged especially when there is the loss of a young child. Ultimately various types of memorials to the lost child which can give significances to the lost out life can be helpful

Concern About Other Disturbed Individuals Including Copycat Incidents

It is only natural that there will be concern on all levels that disturbed individuals who might do anything like this incident should be identified , receive help and be safely  in a place where they can not harm anyone. This problem is accentuated at the time of such an incident and in the immediate aftermath since we know that sometimes in the mind of a severely mentally disturbed person, media reports of this event have  the possibility of precipitating a copycat pattern of behavior in another disturbed person. The presence of mental illness is usually identified by family , friends and teachers at an relative early point in life. While there has been great progress in providing mental health care in the United States since the 1960s , there are still people who do not get the care that they need because of finances and the unavailability of services. Quality health care should be available to everyone and this includes those with mental illness.

The Overwhelming Majority of People with Mental Illness are Not Dangerous

Only a very small percentage of people with mental illness are a serious danger to other people. An incident such as this school shooting invariably unfairly intensifies the stigma towards people with mental illness. This can hinder recovery and adaptation to this condition. We need continued research in identifying people who could be dangerous and we also need to understand and educate the public about mental illness.

The Gun Control Issue and The Psychological Implications.

We don’t yet know the history and the story why the Connecticut shooter’s mother   had registered guns in the house. I would guess that most probably if there were not these guns in the house ( which included automatic weapons ) that untold psychological trauma would not have occurred. The young man may have done something terrible but if guns were not available to him, the   chances are,  not as many people would have been killed.

I also wonder about the psychological effect of his growing up in a household where such guns were owned , kept and valued. I understand the argument that most gun owners may teach their children about gun safety. However when there are guns present, there may very well be the underlying message to a disturbed child, that when you are angry this is the way that you can act.

 

Pain With Major Trauma Injury

It is a great misfortune to sustain a major trauma or burn injury. This brings about the unpleasant sensory and emotional experience of pain. Pain is frequently under treated and can influence ethical decisions being made by the patient and others.

One of life’s biggest misfortunes, is to sustain a major trauma injury. This is especially true if that injury is a burn injury. For many years I was  a psychiatric consultant to  a large trauma center which also had a world class burn center.

When patients would be brought into this center as they are all over the world , the first thing that the trauma team would do is be sure that the ABC’s are under control. As every medical student knows this means:

  • Airway control with cervical spine protection
  • Breathing
  • Circulation and control of hemorrhage

In fact this assessment and immediate care should have started during the first aid that was given to the injured patient. There may be a need for a breathing tube, replacement of blood and even emergency surgery to control bleeding. As soon as possible there will be assessment of the brain and nervous system as well as examination of the body for other injuries and damage.

The patient may or may not be conscious. If they are conscious it is possible that they may be in extreme pain. The important question that I want to focus on is whether they will receive adequate pain medication and how important is it that they receive it. I am not just talking about their care in the emergency room but I would like to address this question as applying to the patient’s entire stay in the hospital.

What Is Pain ?

Pain is an unpleasant sensory and emotional experience associated with tissue damage. Immediate pain may be caused by mechanical or chemical irritation or by tissue damage due to trauma, surgery, disease, debridement, physical therapy, ambulation or any movement. Continuous pain may occur from direct damage or stimulation to the nerve secondary to swelling edema, tissue movement etc.

Peripheral sensations of pain can actually be affected by emotions and the psychological state of the person experiencing the pain. This can be understood by the “Gate Theory“ of pain  which postulates that the pain impulse can be moderated by impulses originating in the emotional center of the brain as well as from the thinking portions of the brain. Obviously, sensations of pain can be altered by medications as well as emotions and thoughts.

Are Doctors and Nurses Trained to Treat Pain ?

About 17 years ago I co-authored a book with Margot Schoeps titled Psychological Care of the Burn and Trauma Patient . We used more than 20% of the book to discuss how to manage pain. We came up with various pain protocols for the management of acute pain after consulting with leading experts in the field. Even though we were mental health consultants, we did this because we knew that at least  1/3 of the 75 million traumatic injures in the U.S would result in moderate to severe pain and that more than 5 million critically ill patients in ICUs units especially those recovering from trauma or surgery would be expected to suffer from episodes of acute pain. We also know that many (but certainly not all) of the doctors managing these patients were not well trained in pain management. We also knew that this pain experience for many patients could have lingering long term psychological effects.

I am pleased to say that there is much more knowledge and know how in pain management today thanks to more sophisticated ER training programs, Pain Management fellowships and an increased sensitivity to pain in the new generations of physicians. Nursing education in pain management has also undergone changes. Pain is now considered one of the vital signs which should be taken, measured and recorded.

Psychological Aspects of Pain

A person may consciously focus on the pain as a symbol of the illness and of the threat to his or her life. A patient may use the pain unconsciously to try elicit a caring response from his or her environment (which includes the doctor and nurses). When pain is inadequately managed, the patient can develop a pain symptom complex which can lead to increasing anxiety, depression and  hostility. It has been shown that a good social relationship can lead to decreased perception of pain and the need for less pain medication

The pain experience during the acute treatment can become an important part of the subsequent post traumatic stress syndrome. Emotions related to pain can be incorporated into flashbacks dreams, avoidance syndrome and in the  physiological  hyper arousal which are the symptoms of PTSD. Pain may be a motivating factor in suicidal ideation

Under Treatment of Pain

Even when doctors and nurse know how to treat pain, it often is not adequately controlled. With the utilization of “as needed” pain orders or self administered pain medication pumps, patients are still under treated for pain. Medical and nursing staff as well as patients themselves (taking their cues from the doctors and nurses) will feel that is better for them if they can hold off  a little longer before taking the next dosage or additional pain medicine. There is often a misguided idea that patients taking pain medication for acute pain will become addicted to the medication and that this can be avoided by delaying or taking a little less pain medicine. This is not true. Patients very rarely become addicted to pain medication because they took it during the acute phase of their injury. Once they are in the recovery phase it is usually very easy to taper off the narcotic medication and switch to another non addicting drug before stopping completely. It is the chronic conditions, which most often  cause drug dependency.

Pain Can Influence Ethical Decisions

I recall one time I was on a panel discussing ethical issues in burn care. On the panel with me was a man who had recovered from a very large burn which left him blind although since he recovered from his burn injury he had become a very successful attorney, married and had two children. However he was making the point that at the time of his acute treatment which had to be quite extensive, with numerous surgical procedures and debridement, he had requested that he not receive the extensive life saving complicated  treatment and he be allowed to die. His wish was not granted and although he did not wish to die at present, he believed that his wishes should have been respected at the time of his acute treatment. I asked him during the question period whether his pain had been adequately controlled. He said no and I followed up by asking him if it had been controlled does he think that he would not have asked to be allowed to die. He thought about it for a long minutes and said “probably not“   .

Psychological Issues For Trapped Miners

33 miners became trapped underground in a mine collapse in Chile. A rescue tunnel will not be expected to be completed for at least 3 months. In order to anticipate the psychological issues which they may experience, similar situations of people being isolated for prolonged periods in the space program, submerged submarines and in Antarctica expeditions are reviewed. Various recommendations to maintain mental health during and after this ordeal are also discussed.

I recently had a phone call from a reporter from the LA Times asking me if I had opinions about the psychological issues that miners trapped in Chile might be having in view of the fact they might be there for another 3 months.

I hadn’t previously thought about this issue and was glad to offer certain possibilities. After the phone call I kept reflecting on this issue. 33 men cut off from their families and the world  in a relatively small space. Except for telephone communication and thin tube which could bring them food and water as well as  whatever small items could fit through the small opening, they were isolated captives. I don’t know what trauma they experienced at the time of mine collapse and whether they had some moments where they felt their life was in immediate damage. We also don’t know whether they still continually fearful for their lives and safety. After all, they are miners and they know the potential pitfalls of the rescue mission being undertaken.

An Event Outside The Usual Human Experience

When people experience a traumatic event that is out of the usual human experience, especially when it is life threatening to themselves or others, that is the major ingredient for developing a post traumatic stress disorder. If they are trained as to what to expect and how to protect themselves, that may help mitigate the trauma. However, as our soldiers have learned, there is no way to guarantee immunity from post traumatic stress. Sensory and sleep deprivation can intensify their response to trauma . The continued presence of the threat to themselves will also exacerbate the psychological symptoms as will the reintroduction of the trauma or something that reminds the person of the trauma.

While the isolation in a mine for this long  duration of time appears to be unprecedented, there are certain situations  where observations have been made on people isolated for long periods of time even with the ability to communicate to the outside world.

Space Travel Provides Model of Prolonged Isolation

The Space program comes immediately to mind where astronauts and cosmonauts were isolated on space stations for long periods of time. Several years ago after one such space trip a Russian cosmonaut wryly remarked, “All the conditions necessary for murder are met if you shut two men in a cabin measuring 5 meters by 6 and leave them together for two months.” With a larger group there is less likely to be intense reactions between two individuals but it certainly can happen.  One report divided the various  psychological responses during prolonged periods in space  into three phases. During the first, which usually lasted about two months, people were busy adapting, usually successfully, to their new environment. In the second phase, there were clear signs of fatigue and low motivation. In the final phase the people could become hypersensitive, nervous and irritable.  In discussing the anticipated expedition to Mars experts have been concerned the ever-present possibility of death by small breach of the space ship by a meteorite or sun flare and how that will effect them. As mentioned above, the trapped miners may very well be attuned to the possibility of some dangerous event where no help could be offered to them

Life on Submerged Submarine or in the Antarctica for Long Periods

Other examples of people being isolated for prolonged periods of time are life aboard a submarine which is on a mission requiring prolonged submersion or life in a remote scientific camp in the Antarctica. The psychological problems which have been noted in these environments include concerns about a limited amount of resources, the unchanging social group, social isolation, limited communication with the outside world, a self-contained ecosystem, the constant sense of danger, physical confinement, lack of privacy, lack of separation between work and non-work, limited opportunity for variety and change, limited sensory deprivation, and dependence on machine-dominated environment. This pretty well defines the anticipated psychological challenges facing the trapped minors. One big difference with those people isolated in the Antarctica  – if one member of an Antarctica team got annoyed with another, he or she would have the whole continent to walk away and be separate for a while. Astronauts and the trapped miners, however, would be very confined with no escape from each other, and they would be very worried about the supply of air and water.

Provide Basic Necessities Plus a Little Extra and More if Possible

The first rule for treating people who may be potentially traumatized is to give them the basic necessities of life plus a little extra when possible. This means food, water, warm dry clothes (or in this case since it is warm down there, dry comfortable cool clothes). The next things that they need are information and communication. They have to have confidence in the people talking to them and know they are receiving honest information. People in a crisis, whether it is on a airliner having difficulty, being in a flood, hurricane or the target of an ongoing  terrorist attack all  want to know what is going on and what is planned for the immediate and near  term future. While they will respond best to truthful information, sometimes it doesn’t help them to give bad news if there is nothing they can do about it.  So for example, sometimes the death of family members is withheld if practical, from a trapped or isolated person until they are rescued. It goes without saying that speaking to loved ones during separation or during an ordeal is usually quite supportive. If a telephone line or radio signal is available a video link usually  can be set up. Providing music, tv shows and broadcasts of sporting events or other entertainment can be psychologically healthy for them also . I understand that some computer games, which are very small and can fit in the small opening, are also being provided. A particular social environment naturally develops with certain people becoming leaders. A 63 year old miner among those down there  has become the spiritual leader according to reports that I read. Recommendations can be made to the miners, which may be helpful. For example it is very important that they maintain a regular sleep cycle, which will be based on the clock rather than on seeing daylight outside. Another recommendation that I heard was being given to them to help maintain their civility and sociability is that they wait before starting their meals until the food for all the miners has been lowered.

Psychological Help During and After Being Trapped in the Mine

It will be feasible for the miners to have individual or group counseling session with mental health experts even while they are in the mine through the communication set up. If needed, psychotropic medications can be prescribed for various individuals and lowered into the mine. Regular chats with mental health professional while they trapped underground even if informal and brief will allow assessment of potential problems, which might require more intensive discussions or medication. I have read about the development of technology to help determine when someone on a phone line is in psychological distress just by their voice characteristics For example, computers can now discern the emotional inflection in a person’s voice to look for signs of emotional trouble. If the computer does find that someone is in need of help, it is programmed to suggest ways to alleviate the problem, such as recommending extra rest, extra food, or possibly medications or the live counselor could do so at that point. Unexpected crisis situations may occur and will have to be dealt with as they occur. One situation, which occurred recently in the Chile mine incident, was similar to situations I have occasionally seen when someone was unexpectedly brought to the hospital. A worried spouse and a girl friend meet each other for the first time as they rushed to the bedside (or in this case to the site of the mine collapse).

It is difficult to anticipate which members of the trapped group of miners will have more psychological issues than the others, both while in the mine and in the aftermath. Perhaps the best indication is whether they have had previous traumas and how they have dealt with them. This is certainly no guaranteed predictor of the future. Even the presence of severe mental illness doesn’t predict problems in this situation. During World War II in Europe there was   a diminished amount of exacerbation of existing mental disease as compared to during peacetime. One of the almost universal responses to an overwhelming trauma is to try to block it out, either by isolating the emotional reactions and/or the memory of traumatic event. People in the midst of traumatic event will report that it seemed as if it were happening to someone else. The degree to which they keep these memories and feelings out of their consciousness can be related to subsequent symptoms, which they may have. Most prominent among post traumatic symptoms are flashback, nightmares, being easily reminded of the trauma with reoccurring feelings or going out of the way to avoid such reminders. Some people resort to alcohol or drugs to try to avoid such painful feelings. Suicidal behavior is sometimes seen in people who feel overwhelmed by their experience and see no way for improvement. These problems when they do occur can be very brief and transient. They may not occur until after a period of weeks or several month from the time of rescue. They can persist for several months or even a lifetime if not treated.

CBT ( Cognitive Behavior Therapy ) has been used successfully in treating PTSD. This is a therapy which consists of correcting negative misperceptions about the experience but also teaching the patient various relaxation techniques at the same time as they mentally re-experience some of their traumatic memories. Other patients will benefit from therapy, which helps them explore the psychological meaning of this experience as well as deal with relationship issues and any resultant drug or alcohol problems.

Resiliency and The Joy of Being Alive

A few years ago I put together a conference of leading experts in psychological trauma and then edited a book with chapters by them on various aspects of disaster. Independently, in each of their presentations and in their book chapter they all made a point of discussing  the resiliency that most people have in dealing with traumatic events. Although many victims of such events greatly benefit by treatment and may have lingering symptoms, the major of  of people in such a situation will have the resiliency, to put this event into some perspective and return to their previous functioning.

Jose Luis Inciarte

Despite clinical experience that mental health professionals might have with people who have been through other traumatic situations, it is still hard to really imagine or empathize how these people are feeling. When I worked as consultant to a burn unit we would sometimes arrange a visit to a patient with a severe burn by a someone who had survived the ordeal that they had been through.

Just this week a Uruguayan rugby player who survived more than two month of isolation in the Andes with 15 others after a 1971 plane crash brought a message of hope for the miners. This survivor, Jose Luis Inciarte said, “They are in the process of discovering the joy of being alive and the will to survive.”

We Can’t Avoid PTSD and Suicides

The army is mistaken in saying that because of PTSD and suicides in the military, “that we are more dangerous to ourselves than the enemy.” PTSD and suicide in the military of are part of war just as injuries and other combat deaths. Soldiers injured by PTSD should get Purple Hearts and families of soldiers who die by suicide should receive a letter of condolence from the President of the United Sates.

The latest information released by the US Army reveals that last year American soldiers attempted suicide at the rate of about 5 /day. There were 160 successful suicides last year and during June the rate was 1/day. Military research has reported that one in 10 Iraq veterans may develop a severe case of PTSD.

We Are Not More Dangerous to Ourselves Than The Enemy

As statistics such as these continue to emerge there is a continued outcry that something should be done about this. A report  issued by the US Army, in my opinion minimized the fact that these psychological causalities are a result combat and the realities of war. The Army review concluded “simply stated, we are often more dangerous to ourselves than the enemy” It went on to say that commanders have failed to identify and monitor soldiers prone to risk taking behavior and as a result suicides among soldier have soared. I believe that this is a misguided view that some somehow if we did the right thing we could prevent these events. There were 250 recommendations in the recent report and the Army has already implanted 240 of them. While these are positive things done to provide good mental health care, they  won’t prevent  PTSD and sadly it won’t eliminate suicides.

We haven’t been able to prevent the increasing number of Americans being killed by IEDs. War is hell and soldiers get killed. We train them the best way that we know how but inevitably soldiers die when there is a war. Maybe one soldiers, despite the best training available isn’t quite as good in a combat zone as another one. Some may be able to know when to zig rather than zag . Some have better instincts than others and that may make them more likely to survive. Some inherently may be able to handle the stress of war better than others.  However, the best training in the world and all the preventive measures in the world will not eliminate combat injuries and death. Nor can PTSD and suicides be avoided.   The most combat savvy soldiers in our military cannot hide from a  bullet with their name on it nor can the most well adjusted soldiers avoid  being  affected by extraordinary human experiences in a war zone.

Of course , we should always strive to improve our training, safety and efficiency in the battle field. Of course we should always strive to provide the best medical care (which includes psychological care) to our soldiers.

Soldiers Injured With  PTSD Deserves to Receive a Purple Heart

Families Deserve Presidential Condolence After Soldier Suicide

We honor our soldiers who are injured serving their country. We give “Purple Hearts“ to soldiers who have been wounded and bury with honor those who have given their lives for their country with the exception of those soldiers who suffer psychological injuries. There is no Purple Heart for them. There is no letter of condolence from the President to the families of those who died from suicide. This is outrageous!  These men and women have all volunteered and knew they could be in harms way. There is no basis for treating them as if they purposefully became psychological causalities. There is no way to minimize the grief of their loved ones but this failure to acknowledge their loss only compounds it.

Five Minute Mood Screening Test

My Mood Monitor (M-3) is a five minute mood screening test which has been validated at a family medicine clinic at the University of North Carolina. It showed excellent results for identifying depression, bipolar
spectrum, anxiety and PTSD. While it appears to be a good screening tool, some concerns were raised about the use of it.

CBR002440There is nothing new about screening tools for mental disorders. However when a topnotch family medicine training program comes up with a check list which they claim can be completed in under five minutes in the waiting room and has very good results, it is worth taking a look at it. The thinking here is that family doctors have less and less time to spend with patients and anything that can clue them in on emotional problems should be helpful

My Mood Monitor is the Test

In a recent journal article in the Annuals of Family Medicine there is a report of the My Mood Monitor (M-3) a self administered 27 item check list that was tested on a sample of consecutive patients who were seeking primary care at the academic family medicine clinic at the University of North Carolina.  Those completing the M-3 were then contacted by a research assistant and asked to take the much longer 15 minutes Mini International Psychiatric Interview (MINI) by telephone in order to validate the results of the M3. The MINI is a well established test that has been validated against the Structured Clinical Interview for DSM  (SCID) which can take up to hour or even more time to administer by a trained person which is more or less the gold standard for research tools using the current psychiatric categories. In this particular study the MINI test results administered by phone were discussed with a psychiatrist before final scoring. If the M-3 is validated against the MINI and the MINI is validated against the SCID, they believe they have test which will be an accurate screening test.check-list

Each of the 27 questions of the M-3  is answered by a check mark in a column which offers the responses:  Not at All, Rarely, Sometimes, Often , Most of the Time. Since just having a bunch of symptoms doesn’t necessarily mean that a person is having diagnosable condition or a serious problem, there were four questions, which assessed if there was a functional impairment. If there were no functional impairments of the person’s life style AND if the suicide question was negative, no further scoring was done and therefore no condition was identified

The test was not set up to pick up psychosis, dementia, marital, sexual or personality problems unless they would show up with significant anxiety or depression, which could very well be the case.

Results

Participants and Completers– 723 people, which were 54 % of the patients approached to participate, agreed to be in the study. 99% of this group also completed the MINI follow-up test.

Diagnosis According to the MINI Test- According to the MINI test, 22% of the people had a depressive disorder (16 % had a major depressive disorder, while 6% had bipolar disorder and 9.3%  had bipolar spectrum illness), 28.1% had an anxiety disorder and 6.3% had PTSD. Overall, 35% of the study participants met MINI criteria for at least one psychiatric diagnosis. 12.1 % had co-morbidity for anxiety and depression.

How Well Did the Brief M-3 Test Do? First of all 349 people (53%) were eliminated from being scored because they did not have a functional impairment. Of the 298 patients who were then scored using the M-3 (meaning that they had a functional impairment according to M-3), 62.4% met the criteria being used for a psychiatric diagnosis. Without going into detailed statistical analysis, it was found that the M3 showed a 95% confidence level for diagnosing depression and anxiety as well as PTSD with a sensitivity and specificity of about 80%. Most screening tools don’t integrate screening for bipolar and PTSD while screening for other anxiety and mood disorders, which is an added bonus. Overall, that is pretty darned good for a waiting room brief screening tool.

Added Benefits of the M-3

Additional questions about the process yielded information that 70 % of the participants reported talking to their clinician  about mood or feelings. 70% said they did so for at least one minute (certainly better than not at all). 63% of all participants reported that the M-3 helped them talk to their doctors about their mood or feelings. Among participants assigned a MINI diagnosis, 75% stated that the M-3 facilitated talking to their clinician about mood or feelings. 83 % of clinicians reviewed the checklist in 30 or fewer seconds. None found the M-3 too complicated and 80% thought it was helpful in reviewing participants’ emotional health.

Words of Caution

Anything that helps doctors become of aware of the patient’s emotional health has to be a good thing.

However, we must keep in mind that 46% of the people approached refused to participate in the study. That number is standard for research but any patient who refused to take a mental health screening test in a clinical practice should receive extra attention by the doctor.

m3hvlogo53% people were not scored because even if they had positive symptoms, since they did not indicate that they had functional impairment or suicidal ideas. I hope that their physician would at least inquire about the symptoms, which were checked, and determine if the patient is having a problem and hasn’t yet come to the point of being impaired or is suicidal or perhaps just doesn’t want to readily acknowledge the severity of the problem.

The paper made a point that the M-3 had questions, which led to a distinction between major depression and bipolar depression. It was stated that the failure to do so can lead to the prescribing of antidepressants without a mood stabilizer, potentially destabilizing the illness and leading to the risk of hypomania, manic or mixed episodes. This is certainly true but I would hope that patients with first time bipolar disorder should ideally not be treated with mood stabilizers without psychiatric consultation. This condition can be difficult to manage and treatment is often not straightforward.

The diagnosis of any major depression may not only require medication, but also close monitoring, especially in the early phase of treatment. When there is the potential for suicidal ideation, an effective dosage of medication can increase the low energy of a depressed patient so they become more of suicidal risk than they were before starting medication.

Medications used for treating anxiety of course can be over used and create serious dependency issues.

Both anxiety and depression can be symptoms of underlying marital and other interpersonal problems as well personality disorders. PTSD once identified usually has complicated determinants and may not be easily treated by just medication.

The multidisciplinary team that put together the M-3 and the testing of it come from both Departments of Family Medicine and Psychiatry. As effective as these short diagnostic tools may be in identifying emotional problems for family physicians, they should be part a systematic approach to diagnosing and treating this condition. Family doctors need to spend more time with patients when these conditions are suspected, diagnosed and are being treated. It is also very important that physicians using the M-3 have a  collaborative relationship  with psychiatrists and other mental health professionals.