Don’t Change the Subject

This is a documentary about suicide, by a film maker who lost his mother to suicide when he was twelve years old. It seems to be his attempt to understand that tragic event in his life at the same time he is making film that he hopes will save some lives. Usually we don’t review films before they are ready to be released. In fact, the final edit on this movie has just been tweaked. It hasn’t hit the film festivals yet and a distribution deal has yet to be made. We hope in a small way, the availability of this review will help the process along as well as encouraging folks in the mental health community to consider using this film as a discussion tool at professional meetings and most of all to be used for educating the public.  According to the National Institute of Mental Health suicide is 10^th leading cause of death in the U.S. and the 3^rd leading cause in the age group 15-24. There are 11.3 suicides deaths per 100,000 people in this country. An estimated 11attempted suicides occur per every suicide.

While these and other statistics are important, this film is not about numbers and risk factors. It is about real people who tell little pieces of their stories. It is about people who came very close to killing themselves but for some circumstance or reason didn’t do so. It is about the filmmaker who comes across as a very likeable guy who is trying to figure out why is mother, who he believed loved him, would leave him by her own hand. He reads her letters, listens to tapes of her talking, looks at old film clips and ponders this issue with his older brother, aunt and step mother who married his father after his mom died. His brother never understood how she could have done this when she was in the music business and knew how important was his debut as an opera director that was happening the following week. His aunt, who was a psychiatrist, knew her sister had problems but didn’t see this coming. His stepmother only recently reveals her own special connection with suicide.

Sally Stutz

While the filmmaker may not have ever completely understood why his mother ended her life, he did realize that more then how she ended her life, she should be remembered for how she lived her life which included much love and support to her children. This message alone gives the film great value.

The filmmaker, Michael Stutz is also the director, writer and producer. He does go beyond just his own story and some close up vignettes of people who struggle with depression and have come close to doing this fatal deed. He follows a talented choreographer who is preparing a group of young dancers to perform a piece about autopsies. The result is as dramatic as is the meaning to young performers who had to come to grips with what their dance was about. We are introduced to a fairly successful comedian who has a team of writers help him prepare his material that daringly enough is going to be about suicide. It is always tricky business when humor is touching a potentially raw nerve. You have to understand, as a psychiatrist I usually don’t even like it when people use the word “crazy” in stories or in every day life but I appreciated the use of humor in this film. In fact the highlight was a piece by a comedian who did a monologue as a character who was leaving a video to his family prior to his suicide. He said just about everything a loved one would dread that their family member who was ending their life might say about them and how the suicidal person felt about them. It brought me to out loud laughter and will be for me one of the most unforgettable parts of this film about a very serious subject.

I said earlier that I hope professionals will view and use this film in their efforts to prevent suicide. It is not because this film will necessarily educate my profession about suicide. It didn’t really examine the difference between suicide attempts and suicide gestures nor did it attempt to show the different psychiatric diagnosis that people who attempt suicide might have. In fact there wasn’t much of a psychiatric presence in the film. However it has the potential to be very meaningful to anyone who has struggled with suicidal thoughts, had fleeting suicidal thoughts or has been close to anyone who has had these issues. Unfortunately there are a great number of people in at least one of these categories. This film can save lives so it deserves to be seen and will be a worthwhile experience for many people. I don’t know yet when and how it will be distributed but more information about it can be obtained on the following website: http://www.dontchangethesubject.org/ (2011)

Q & A with Michael Stutz

Shortly after I viewed the movie, I spoke with Michael Stutz, the filmmaker and he agreed to answer some questions for this blog.

MB: What made you decide to make this film?

MS: I wanted to make a film that I would have wanted to see when I was a kid dealing with my own mother’s death.  At that time I was struck by the typical adult reactions when talking to a twelve year old and how incredibly awkward they were.  Everyone seemed to be walking on eggshells.  If they talked about it at all it was in vague clichés or condescending attempts at “she’s in a better place.”  My mother was in and out of mental institutions for more than two years before she died.  I watched her sob and collapse and sleep for eighteen hours a day.  I also was the one who found her after her overdose.  I didn’t need clichés.  I needed honesty and a path to help me process my feelings and move on.  For me that path turned out to be theater and comedy and dance.  You can’t really capture all of the raw emotions going on in your head after something like this.  It’s surreal.  The arts helped me to work through images, fragmented thoughts and deeply conflicted feelings better than a straight on discussion could.  With this movie I wanted to suggest different ways of communicating beyond conversation.  It’s incredibly important to talk about it but not everyone is able to talk about it in the same way.  As I sit down to write this I am remembering the one adult who really helped me the day I found my mom.  It was a friend of my grandmother’s who came over to watch me while everyone else was at the hospital.  I was crying and she sat down and instead of clucking out soft meaningless words she showed me a book of watercolors she had painted over the years.  She said she normally didn’t show it to anyone but thought I might like it.  We just looked at the trees and lakes and various images that she had created and it calmed me.  I see now that’s a part of what I wanted to do with the film.  Share something private in the hopes that it might help somebody out in their own time of need.

MB:Is there a special audience that you had in mind when you made it?

MS: I made this movie for members of the suicide community who would cringe at being identified as part of the suicide community.  Over the years I’ve taught a lot of classes to various groups, teens in particular.  I’ve taught theater, comedy, dance etc. and I always find the kids I like the best and the ones who ultimately seem to get the most out of class are the ones who were the most resistant and cynical in the beginning.  The smartasses, the awkward shy kids, the kids who think they would rather be anywhere but in that class.  I made this movie for them.  Our movie is a punky, awkward, smartass, oddball little film for everyone who feels like they’d rather be anywhere but in a theater watching a suicide movie.

MB: Was it therapeutic for you to go through the process of making this film?

MS: Absolutely.  Though I have to admit when we started out my concept of the film was very different than the film that ended up on the screen.  I thought I’d interview several well-known people in the arts who had experienced suicide in some way and then see them creating their own artistic pieces.  After being turned down by everyone that I asked, I realized first how incredibly taboo this subject still is, and second that I’d have to be willing to step up to the plate and share my own story if I was going to ask others to do the same.  So then my family got dragged into it.  At the same time we were making the film my stepmother Judith was in the end stages of cancer.  Because of this she and I had been having a lot of conversations about family, including something that I didn’t know when I was a kid; her father had killed himself too.  She had held his head after he’d shot himself just like I had cradled my mother’s head after she overdosed.  Her father killed himself just before her birthday, just like my mother had done before mine.  It was amazing that we had lived under the same roof and never talked about this.  So, as Judith was entering hospice and going through her last year of life we were also filming this movie with family as they visited.  It was an incredibly bonding experience.  Judith was very involved with the whole process and always asked about its progress and was even able to see the first full rough cut three days before she died.  The conversations we had both on camera and off were some of the most rewarding and meaningful conversations I have ever been a part of and I think she felt the same way.  I will say it’s amazing that it took a camera to help all of us in the family to talk to each other in ways we never had before.

MB: How did the comedy piece of the character making the video for his  family before he killed himself, come about?

MS: There’s a comedic monologue called “Daddy’s Last Video” in the movie that I wrote several years ago for a brilliant actor named Ron Riegler.  He’s quite simply the funniest and most subtle actor I’ve ever worked with and I knew he could pull this off.  It came from my experience as a child where people would come up and say various versions of “this wasn’t your fault.” This is of course a very kind and reasonable and I’m sure in many cases very helpful thing to say.  But then again what is the alternative?  What if someone, in this case the daddy who killed himself, said in those same low and comforting tones, ‘well actually this is your fault.  You really were a lousy little kid.  Thanks for killing me.  Love Daddy.’ Now, out of context I’m sure this reads as horrifying but you have to see it to understand that I’m simply pointing out the ridiculousness of almost anything you say to a kid after a parent has killed him or herself. The situation is so bad it becomes absurd.  I guess I just hate low, hushed-toned speaking.  As a kid I thought, “Really, this isn’t my fault?  No kidding?  I just found my mom on the bed and that’s the best you can do?  Thanks.”  But, I was a weird kid.

MB: Were you concerned that this piece or any of the other humor would be found offensive by some people?

MS: I’m sure right now someone reading the previous answer is thinking ‘seriously you want me to see a movie where children are blamed for their parent’s suicide?’  I promise, it’s funny in context.  So yes, I’m sure it’s possible that some reasonable people could be offended by this or other parts of the movie.  But what I’ve found so far is that most of the people who have seen it who have experienced suicide up close and personal have laughed right along with it.  I’ve met with more resistance from those outside that world who worry that we may offend.  Gallows humor is what I do.  I’ve done plays and sketches about all sorts of issues related to mental illness.  I promise you they aren’t done to mock these very serious issues.  I was raised on Monty Python and Woody Allen.  I blame them.

MB: What kind of responses have you had from people who have seen the film ?

MS: We’ve gotten very positive responses so far, especially from folks in the psychiatric community.  I was somewhat worried that because the film is a little more “colorful” with its language in some places and does use humor to deal with very heavy issues that some folks might not be willing to take the trip with us.  But so far I’ve been very pleasantly surprised.  It’s also been great to see a broad range of people get something out of this.  A friend of mine pointed out that even though he hadn’t experienced suicide in his immediate family the way he felt after his parents’ divorce was very similar to how I felt after my mom’s death.  In some ways you could say that the movie isn’t primarily about suicide.  It’s about communication.  Everyone has had a time in their life when they felt misunderstood or unable to communicate their feelings.  That’s what we’re talking about.

MB: Do people “change the subject” when you discuss the content of the film?

MS: When I say I did a movie about suicide people usually drop their eyes and mutter something under their breath while trying desperately to inch their way away from me.  But when I say I did a weird dance comedy performance art movie with kids performing to autopsy reports and comics flipping out on rooftops and dark little animation sequences then the eyes sort of come back.  In the end many of the loveliest parts of the movie are actually the quiet, sometimes sad, sometimes funny little moments where survivors are relating their stories in this heartbreaking but incredibly inspiring way.  But since a lot of folks can’t quite wrap their brains around that we give them some other fun things to look at in between the stories.

Long Campaign to Change

There has been a long standing campaign to get the President to change the previous policy, led by families who had soldiers die by suicide. Various veteran groups, members of Congress and  mental health professions, including myself have been publicly advocating that the President change the policy.

The Keesling  Family

I first wrote about this issue in my blog (Psychiatry Talk.com in December 2009) after reading a NY Times piece the previous month about the tragic loss which the Keesling family suffered when their 25 year old son Chance killed himself in Iraq in June of that year. He was in his second tour of duty when the stresses of combat combined with an argument with his girl friend over the phone led to hopelessness and suicide. Hours before his self-inflicted fatal gunshot wound the Keesling family received a rambling despondent email message from their son.

Chance Keesling (Photo from the Keesling family)

His father Gregg commented on my blog and we began a correspondence about this issue. He and his wife had decided to share some of their grief with the public in order to try to bring about a change in the Presidential policy, which was so hurtful to his, and other families who suffered similar losses.  They would receive a folded flag, a letter from the Army praising their son, a rifle salute at his burial and financial death benefits. But the letter of condolence from the President of the United States, which is the symbol of the voice of the people of our country, which is sent to every other fallen soldier in war since the presidency of Abraham Lincoln, was conspicuously absent. There was an increasing frequency of articles touching on this subject in the media. I wrote about it again in my blog and in the Huffington Post and received more comments than any other pieces that I have written. The House of Representatives voted in May 2010 to add an amendment sponsored by Representatives Burton and Napolitano to the Defense Authorization (HR 5136) that urged that the policy be overturned. The only response from the President was that this policy was being evaluated.

Why There Was Resistance to Change ?

It was difficult to say exactly why there was resistance to changing this policy. It appeared to come from certain factions within the military who had the misguided idea that such recognition would encourage suicide or would be rewarding those who were “weak” and couldn’t deal with stresses compared to those who did. These ideas were antithetical to the fact that there were so many accounts of the comrades of these soldiers who did die from suicide who were quite devastated by these losses and very supportive to the families of their fallen comrades and to their memories. There also was no psychological basis for such theories. I could not help but feel this was another example of the stigmatization of mental illness.

American Psychiatric Association Weighs In

As a Past Speaker of the Assembly of the American Psychiatric Association (APA) I believed that it was important that American Psychiatry speak out on this issue. I wrote an Action Paper (a resolution) with Dr. Roger Peele of Washington D.C. which was also co-authored by Drs. Catherine May, Eliot Sorel, Hind Benjelloun and Joseph Napoli which was voted upon and approved by the APA Assembly in May of 2010. The Board of Trustees of the American Psychiatric Association then approved it. In July 2010 James H. Scully Jr. M.D., CEO and Medical Director of the American Psychiatric Association wrote to President Obama representing the 37,000 psychiatric physicians. He called upon the President to eliminate the stigma and shame associated with suicide for families and survivors by reversing current policy and forwarding Presidential condolence messages to families of individuals who complete suicide while in military service. In October of 2010  the APA issued a public statement urging President Obama to reverse the policy of barring such letters. A number of other mental health groups including the American Foundation for Suicide Prevention and the Mental Health America had officially come out in favor of this policy change. APA President Carol Bernstein, M.D. issued a statement in which she noted, “ The contributions of these men and women to their country are not less for having suffered a mental illness. A reversal of this policy to allow condolence letters to family members will not only help to honor the contributions and lives of the service men of women, but will also send a message that discriminating against those with mental illness is not acceptable.”

The Long Awaited Change

The number of suicides in the military continued to go up either approaching or in some analyses exceeding the number of combat deaths. The problem of PTSD and the mental health of our combat troops became a high priority of the military but there was still no change in the Presidential policy.

Last month (June 2010) I met with Gregg Keesling for breakfast as he was in Los Angeles for a business meeting. He had received some indication that the President was reconsidering his policy but nothing had come down yet. Senator Barbara Boxer had just sent a letter to the President, which was made public.  We reflected in our discussion whether this issue might come to a head sooner if fate had led to a high profile family to lose a military family member to suicide rather than unknown but valiant people such as Gregg and his wife. It was clear that he and others like them in memory of their lost loved ones were not giving up the fight and were continuing to push for a change in the Presidential policy.

The Keeslings were notified in advance of the official announcement that henceforth the families of soldiers who die in a combat zone by suicide will receive a Presidential letter of Condolence. They understood that this would not be retroactive but were nevertheless overjoyed that the battle that they had fought in memory of their son was won. While there is nothing that relieves the pain of the loss of a child, hopefully the significance of this accomplishment will help in a small way.

I certainly am very pleased that the President has seen fit to make this change in his policy. I imagine that it was not an easy thing to do since there apparently was strong resistance in the military.

Still Unfair Discrimination

Coming Home (Photo from the Keesling family)

However, it should also be pointed out that there is still something inherently unfair and discriminatory about the new policy. As I understand it, letters of condolence will only be sent to families of troops who have killed themselves in a war zone. I am certain that if a soldier is critically injured by an explosive device but does not die until he or she is back in the United States receiving treatment, his family would not be denied a letter of condolence from the President. Similarly what if a soldier develops a mental disorder related to the stresses which he or she is experiencing in a combat zone and is transferred to the US to be treated but unfortunately succumbs to this condition and commits suicide? Shouldn’t this soldier also be considered to be a combat victim and shouldn’t his or her family also receive a letter of condolence.  Sometimes changes come in small increments and perhaps this important step and the attention to this issue will help the destigmatization of all mental disorders.

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.

In a recent blog I wrote about empathy and how we might try to teach medical students to be empathic physicians. Psychiatrists, other physicians and therapists try to put ourselves into our patient’s shoes (or skin) in order to understand how they are feeling in regard to the things which are troubling them. When we do psychotherapy we often approach this with an added dimension. We know that the patient will usually experience the therapist in a similar manner to how they experienced important people in their early life, most probably their parents and/or siblings. Freud has dubbed this situation as transference and for certain types of psychotherapy understanding the transference and using it in the therapy can be very helpful. In fact, for psychoanalytic and much of psychodynamic therapy, it becomes the essence of the treatment.

Social Empathy

I was recently made aware of another aspect of empathy which I never thought about before and which I would now label  “social empathy” . My consciousness to this form of empathy was raised when I read about a blog called Postsecrets which weekly displays anonymously mailed-in secrets on artistic postcards from across the country. It has been around for several years and has long been known for revealing suicidal secrets. It has set up a phone hotline in response since the blog began in 2004. Recently a postcard read, ” I have lived in San Francisco since I was young…I am illegal…I am not wanted here. I don’t belong anywhere. This summer I plan to jump off the Golden Gate Bridge.”  According to a blogger Kristi Oloffson .within 24 hours nealry 20,000 people had signed up for a Facebook group titled “Please Don’t Jump, which was later linked beneath the secret on the Postsecrets blog , linking in thousands of supportive comments. On the group’s page, sympathetic users posted comments ranging from simply “I want you here” to “If I knew when you’d be at the bridge, I’d drive all the way from Ohio to meet you there, and hold you until you changed your mind.”  A video about this phenomena has become the most viewed video on the Time Magazine web site.  ( For information about the issue of suicide from the Golden Gate Bridge please see two previous blogs I have written on this subject , Suicide Jumpers From the Golden Gate Bridge and  More on Jumpers, The Movie ).

I checked it out and sure enough and as of this writing there are more than 60,000 people  who have tuned in to this secret and obviously felt an empathic response which they posted on the Facebook site. It may have been that this group comes from a populations which were drawn to the  Please Don’t Jump Facebook page because  they themselves are in touch their own secrets and feel for someone who has this one.  Others without being aware of their own secret may also just want to reach out to someone else whose pain they can feel. It is also clear that people responding to the would be San Francsico jumper are not mainly other immigrants who are in a similar plight. They seem to come from all age groups, geographic areas and different backgrounds as best as I could tell scrolling through a sample of the now more than 60,000 responses.  I believe that it is the identification with loneliness  and isolation which  is the universal  piece that many people have felt at some time in their life which is connecting people with the San Francisco postcard sender.

Implications For Psychotherapy

I don’t believe that social medial will replace the role of psychotherapy. However, it does appear that there is a natural role that it is playing in the support of people who are feeling psychological pain. This new media is clearly interdigitating with other  forms of psychological support and there is no reason whey they can’t overlap. We should be asking patients if they have had  previous psychotherapy, whether they have been treated by any self help groups as well as including an an inquiry whether they  have been interacting with the social media in regard to their current or other problems.

]]> http://www.psychiatrytalk.com/2010/06/60000-empathic-responses/feed/ 2 http://www.psychiatrytalk.com/2010/06/consulting-on-a-suicide-epidemic/ http://www.psychiatrytalk.com/2010/06/consulting-on-a-suicide-epidemic/#comments Thu, 10 Jun 2010 06:45:22 +0000 Dr. Blumenfield, M.D. http://www.psychiatrytalk.com/?p=1096

13 Suicides In One Factory in China

According to recent reports from China, since the beginning of the year 13 workers form Foxconn a large factory in Shenzhen have committed suicide. Foxconn manufactures products for Apple, Hewlett Packard and Dell. Some reports in the media tell of difficult working conditions where plant workers could not talk while working and were fined for mistakes. The average salary of workers in the factory was $140/month but since the reports of suicide, it reportedly has been raised 66%. On the other hand, in an effort to discourage suicides, the factory has stopped offering compensation to families of those who have killed themselves since it must have been thought that this compensation might be an incentive for some of the workers to commit suicide. It is also reported that some of the political leaders in China are unhappy with the bad publicity that this rash of suicides has been bringing to China and are taking steps to stop it. Nets are  being built around the dormitories where many of the workers have jumped off in their suicide attempt. More appropriately counselors were being trained and brought in.

Similar Situation in the United States

This situation reminds me of a somewhat similar set of circumstance in which I had been involved. Many years ago I was asked to be part of a small team to study a series of suicides that had occurred at a large entity that was frequently in the public eye. The press was clamoring for answers about this unusual problem and management was concerned about the bad publicity. They assured us that they would do whatever they could to help us get to the bottom of  this problem and expected a full report from our team within 60 days.

Approach to the Consultation

Our first step was to meet with the managers and supervisors, as well as the union leaders. Management agreed to help us in any way but the union people were suspicious that we were going to whitewash the problem.  After much discussion and many meetings, we convinced them that we were independent of management and although we would ultimately be reporting to them, we would pull no punches. They agreed to encourage full access for us. This initial step was very important.

We obtained the all records and documents of the workers who had suicided. We attempted to meet with their co-workers. Although meeting with their families would probably be enlightening, we ultimately decided not to do so. Since  much of the work of this entity involved vehicles driving from place to place we arranged to ride with them and chat informally in addition to the structured interviews that we did as noted above.  As some of the emerging information indicated that working condition, time schedules, salary, benefits and opportunities for advancement might be an important factors in the suicides, our team made an effort to benchmark this entity in regard to these factors  using similar entities in other cities in the US and internationally.

Findings

We found that there was a great deal of demoralization among the highly skilled work force which may have contributed to the suicides. As far as we could determine, most of the employees were very dedicated to their work but felt that management did not care a great deal about them. They were expected to frequently work overtime (with pay) but often did critical work while sleep deprived. A small undetermined percentage took drugs mostly to stay awake and mentally sharp (some to deal with their demoralization and depression). We heard of examples of workers doing work which could endanger other’s lives while under the influence of such drugs. They felt that their work skills were not easily transferred to other jobs and also  believed that there was little chance for advancement within their current job. There were some circumstances where workers became psychologically traumatized related to their work.  However most people whom we interviewed shared the belief that if they complained of being depressed, anxious and not able to work , they would be penalized in the job.. We had the impression that this lack of support contributed to the suicidal behavior which had occurred in at least several instances.

Our study team prepared an extensive report with these findings and with a list of constructive suggestions which was based on our interviews and our benchmarking inquires. We suggested policies concerning time off , breaks and areas where breaks could occurs. We advised  drug and alcohol educational programs with a guaranteed no penalty for those who sought help for these issues or any mental health concern which should not be part of the employment record. We suggested a review of the salary, vacation  pension and promotion policy   based on the preliminary information that we had from our examination of other similar entities. We did not think that meaningful changes would be a financial burden and in the long run would provide more efficient functioning. We also suggested a mentoring program utilizing senior people, many of whom were held in high esteem by the younger workers.

Consultation Report Initially Rejected

We were surprised at the total rejection of our report by the highest level of management. They told us we would have to rewrite the report or we would not be paid for our services. I believe that they had expected us to confirm their belief that the people who suicided were mentally unstable and not typical of the work force. While that was true in some of the cases, we obviously felt that there were factors stressing the workers and that suicidal behavior was one result of these factors which needed to be addressed. It also appeared that the highest level of management was concerned that his report might be leaked to the press which of course we had no intention of doing. Ultimately the report was accepted as a confidential report. Some but not all the recommended changes were made over several years. The unusual number of suicides did not continue and in fact  may have been a coincidence which unearthed some problems which needed to be addressed.

Recent Research of Studies of Antidepressant Medications

A recent study in the Journal of the American Medical Association reviewed six well-done research studies, which  looked at  double blind placebo of antidepressant treatment for at least six weeks  with adult outpatients who had  minor and major depression. The usually reliable Hamilton Depression Rating Scale ( HDRS ) was the instrument used for measuring depression.

Medication Works Best With Severe Depression

The researchers concluded that the  magnitude of benefit of antidepressant medication compared with placebo increases with the severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial. It is important to note that this information does not deny that many or probably most of the patients in these studies as they do, in doctors offices all the time, felt much better after taking antidepressant medication. The placebo effect of taking the medication and/or various forms of psychotherapy or general support caused improvement in people who also were taking antidepressants. Only in those patients with severe depression was the improvement clearly (or statistically) better than those were taking the placebo.

Considerations Whenever Depression is Diagnosed

The implications of this research should not be a surprise to most practicing psychiatrists. When treating depression, one must take into consideration many other factors in addition to the presence of depression symptoms.

Medical  Conditions

Is there an underlying medical condition, which might be causing the depression, or contributing to it?  If  there is such a condition, it is quite possible that any antidepressant treatment will have limited effects unless the underlying condition is addressed. While there might be some improvement above and beyond placebo effects with medication, the chances would be much better if attention were directed to the organic conditions. Even just the recognition that there is a medical cause will often help to alleviate the depression as the patient begins to understand the nature of their illness.

The list of medical conditions, which can cause depression,  is quite long. Some examples which are far from inclusive are as follows:

1. Thyroid condition particularly hypothyroidism
2. Other endocrine abnormalities such as parathyroid disease and even diabetes
3. Various forms of epilepsy
4. Brain trauma or vascular insufficiency to the brain including stroke
5. Brain Tumor can often first be manifested as depression
6. Infectious processes particularly those that can effect the brain such as Lyme Disease or Syphilis
7. Parkinson’s Disease and other degenerative diseases such as Alzheimer’s; Disease or Huntington’s Disease
8. Cancer of Pancreas is known to first show itself as depression but so can other cancers
9. More exotic diseases such Wilson’s Disease, Huntington’s Disease or even Pellagra, a rare vitamin deficiency

Bipolar Disorders

Of special  importance are Bipolar Disorders where the  depressive phase can be indistinguishable from a severe depression other than by a  history of a manic phase. Antidepressants if used in these conditions may actually make things worst by precipitating   a manic phase whereas mood stabilizers can bring about great improvement.

Schizophrenia

While Schizophrenia is usually relatively easy to diagnose, there can be a depressive component to this disorder. At times if the underlying schizophrenia is not recognized, the use of antidepressants alone will most likely not be effective . These patients usually require an antipsychotic medication to put the condition into remission.

Obsessive-Compulsive Conditions and Phobias

Obsessive-Compulsive conditions and severe Phobias may respond to antidepressant but specific classes of these medications have been shown to be most effective. Thus if these conditions are not recognized, the wrong medication may be chosen. In addition these disorders usually require additional forms of specialized psychotherapy.

Dependency & Addictions

The failure to recognize alcoholism and drug dependency and to just direct treatment towards the depressive symptoms with antidepressant medication is doomed to failure. Since such conditions can ultimately be fatal such an omission is quite serious. Other dependency conditions such as compulsive gambling , sexual addiction, and even eating disorders while perhaps not technically classified in this category are similar in that specialized treatment is absolutely required . Antidepressants may also be helpful but by themselves will not significantly improve these conditions.

Character Disorders, Interpersonal,  Psychodynamic Issues & PTSD

People with these conditions can appear in a psychiatrist or other mental health professional’s office or they can even be recruited into a drug study. If they have depressive symptoms they may be put on antidepressant medications. They may have some improvement  because they have a dual diagnosis with a depressive condition or because of placebo effect. However,  if the underlying condition is not addressed with a meaningful psychotherapy, which is effective for them, the depression will most likely reoccur. In a large percentage of these patients the use of antidepressant may very well be judged to be ineffective. As in all the above conditions unless both diagnoses are addressed it is most likely that the antidepressant will fall short of significantly helping the patient.  On the other hand sometimes in many of  these conditions and those mentioned above, if a serious  depressive component is recognized and treated, the patient will become more able to relate and engage in treatment of the co-existing conditions.

Grieving

I left this condition for last because the manifestation of it  can often resemble major depression with insomnia, poor appetite, and diminished interest in the world, severe depressed mood. Obviously, the history of the loss as well as other specific characteristics distinguish grieving. In most cases it is time limited. Sometimes supportive therapy or even specialized groups are helpful. If these symptoms become incapacitating, or if there is a history of previous depression a trial of antidepressants may be used.

Dual Diagnosis

As was mentioned above, there can be two conditions present at once and one of these may be a major depression which requires antidepressant medication as well as treatment of the other conditions. Therefore, when treating any psychiatric problem a careful history should always explore for previous signs of depression as well as family history of it.

Suicidal Thoughts

The other special condition that should always be considered during diagnosis and treatment of any patient where there is a depressive component is the possibility of suicidal ideation. Obviously, this is a serious and difficult condition to detect and manage and I won’t go into detail here other than to emphasize it should always be in the mind of the treating psychiatrist or mental health professional involved in treatment.

Split Treatment

Any discussion about the treatment of depression with medication should mention split treatment which mostly occurs when  another mental health professional is treating the patient with some form of psychotherapy and a psychiatrist is  prescribing the medication. In view of all the other complicated and interacting factors mentioned above including the manifestations of suicidal ideation  there must be very good communication between both professionals if there is this type of a treatment arrangement. Some of my colleagues are not comfortable in sharing such treatment. I have found that if you have a good working relationship with the other professional such a treatment plan can work effectively. Similarly at times a psychiatrist is a consultant to another physician or another mental health professional will work with non psychiatric physician. In the future I shall try to examine various potential pitfalls and advantages of split treatment .

Conclusion

I believe the antidepressant medications that we have today to treat patients with depressive condition can be extremely effective. I know that they have saved many people’s lives and relieved an untold amount of suffering. If used indiscriminately and not properly monitored they can be dangerous and also allow conditions that require other treatment to go undiagnosed.

I welcome your comments on any aspect of this subject whether you are a mental health professional, a patient or anyone  interested in this subject.

One of the comments that I received on the blog was from Dr. David Goldberg a psychologist from Birmingham, Alabama who noted that there was a powerful and chilling documentary film titled  The Bridge about this group of people.  I put this DVD on my Netflix queue and just recently viewed it.

The Making of the Movie

In 2003 Eric Steele a film maker living in New York read an article  in the New Yorker titled Jumpers by Tad Friend which described the unsuccessful 50 year campaign to put a barrier on the Golden Gate Bridge to prevent suicides. Steele imagined the human misery that people must be going through as they take their last walk and became inspired to make this film. He gathered the huge amount of equipment that was necessary for this project and journeyed to San Francisco. He placed ads in venues like Craig’s List and gathered a film crew who, while  impressed with the filmmaker, had some trepidations about the project. After obtaining all the permits needed and teaching the novice camera people about the technique, they first encountered the National Guard who thought they were terrorists with 9/11 only two years behind them. After this misunderstanding was clarified they  trained their cameras on the bridge and set up their death watch for the entire year.

24 People Committed Suicide from the Golden Gate Bridge in 2004

In the year 2004, 24 men and women died from the tremendous impact of hurling themselves from the Golden Gate Bridge. Many of these people were filmed as they took their last walk and their final fatal action. Some appeared to ponder the meaning of their anticipated suicide as they stared at the water or the beautiful San Francisco’s skyline  for varying amounts of time  before lifting themselves over the railing. One man made several cell phone calls before going over. Some appeared to be flailing as they fell, one dove like a bird, another fell backward and  one woman was grabbed back to safety before she could jump by a nearby tourist who happened to be taking pictures

The Fatal Jump and the Pain of Family and Friends Captured on Film

The end result of this project was a beautiful and poignant film, which not only captured the last moments of these troubled folk’s  lives but also was able to tell their stories and show the impact on the people who knew them. The filmmakers were able to gain access to many of the families and friends of the ill-fated twenty four people who ended their own lives. They created an atmosphere where these people seemed very comfortable talking to the film makers and talk they did.

As I watched the 94 minute movie unfold, I was initially listening with my clinical ear. This person obviously was schizophrenic, that person had a bipolar condition and another person was a methamphetamine user. It registered on me how many were taking their medications or appeared to be under vigilant psychiatric care. Others seemed to be making the decision to jump after they stopped their medication. One woman couldn’t sleep because of side effects of medications. Were they giving clues as to their intent? Was there a history of a cry for help.? At first I was thinking to myself wouldn’t this film be ideal to show to mental health professionals because it has so many good clinical vignettes.

But probably a quarter of the way into the film, I easily put aside my intellectual analytic approach as I felt the emotions of  the personal stories. I became  acutely aware of the continued  suffering of the victims who eventually chose to go over the rail and so much of the deep pain of those who knew them quite well. My heart would race as the camera scanned the faces of those looking out into the abyss, never knowing which one would be the one who could bear living no longer and would suddenly lift themselves up and leap into the water. I was deeply saddened as I heard the parents who understood the hopelessness of their child who ultimately took the plunge. I could feel the frustration of the people  who had dealt with previous suicidal threats of friends but didn’t think that they would ever do the deed. Although no clinicians of the jumpers were interviewed I could empathize with the therapists who must have know that some of these people were chronic suicidal risks but had chosen or felt that they had no choice but to do their best to treat then as outpatients.

The Story of One Who Survived the Jump

Probably the most dramatic part of the film was an interview with a 25 year old man who survived a jump from the bridge and ultimately became a spokesperson for suicide prevention. He had a bipolar disorder and was suicidal many times before and had depressive episodes at least three times after the jump. His story was similar in many ways to the case reported in the journal article I mentioned at the beginning of this blog but was actually a different person.  The moment he let go of the rail of the bridge and began his descent, he regretted his decision. He miraculously successfully positioned himself to hit the water in a survival position although going probably at least 120mph . He fractured bones and vertebrae and his initial survival was apparently aided by a seal which held on to his body while rescuers were arriving. There also was an interview with his father who received the word that his son jumped from the bridge that should be inevitably fatal but he was told he was alive. He will never get over what has happened that day nor will all those who knew the other fatal jumpers. Most will get on with their lives, some with therapy, some without but no one will forget .

It is All on Netflix With Three Special Features

Netflix DVDs often have some extra features which in this case consisted of an interview with the filmmaker Eric Steel, another of a brief public service announcement for suicide prevention by the guy who survived the jump and a third piece which were interviews with the young men and one women who were the camera crew over this year project. They did not quite realize what they in for when they signed up for this gig. They told of their initial experiences of scanning the faces of so many “suspicious“ people who  might be potential jumpers, as they had  one finger on the their cell phone connected with speed dial to the bridge police and the other on the camera button. They did capture the last moments of people jumping from bridge which appeared to have a profound impact on them. One of them said that he is  sure they will live with that experience for the rest of their lives.

Impact on  the Camera Crew

Those of us in the mental health field know how dealing with traumatic events can have a long lasting effect on the observers. We sometimes set up group discussions for the helpers and on occasion some personal therapy may be useful for such caretakers. At various times in the past I was involved in providing such services for members of our burn unit at a hospital where I worked as well as nurses working with dialysis and transplant patients and also various personnel including members of the media after the World Trade Center attack in New York. We know that most people have the resiliency to come through such  event without requiring formal therapy but it should be available when needed.

While this camera crew may carry indelible memories of what they have seen, they have also , helped to make these tragic events a little bit more understandable to the people who see this film whether they be lay people or mental health professionals. So in some way they have allowed the abrupt tragic ending of troubled lives to have some beneficial meaning to future generations.

If an American soldier is wounded and then dies or is killed immediately in Iraq or Afghanistan,  the President of the United States and The Secretary of Defense write a condolence letter to the family. However, if an American soldier is wounded physically and /or psychologically during his action in Iraq or Afghanistan and then commits suicide there is no letter of condolence written to his or her family by the President and the Secretary of Defense.

There are now more suicides among our combat troops than all those killed by enemy fire in Iraq and Afghanistan together according to a recent CNN Report on this topic. There have been 354 suicides thus far in the year 2009 which is more than the 335 total of combat deaths which occurred in Iraq and Afghanistan combined . While most of the suicides don’t occur until the soldiers have returned to the states at least one third have taken place in Iraq and Afghanistan. The US Army and the National Institute of Mental Health are partnering to assess risk and resilience in service members in an epidemiologic study of mental health, psychological resilience, suicide risk, suicide-related behaviors, and suicide deaths. While this is quite important, it does not address the failure of our leaders to knowledge the sacrifice of those psychologically injured soldiers who commit  suicide. This is a serious defect in our moral fabric.

While Presidents since Lincoln have been writing letters of condolence to families, there is apparently unwritten policy that this does not include families of soldiers who have committed suicide. It is easy to imagine how hurtful that must be to a family who is burying a son or daughter who came back from war with psychological problems and then committed suicide or perhaps killed themselves while still overseas. The New York Times recently wrote a story about one such family. After Gregg and Janet Keesling’s son, Chancellor, killed himself in Iraq in June, the family received a folded flag, a letter from the Army praising their son, a 21-gun salute at his burial and financial death benefits, but not a letter of condolence from President Obama.

A spokesperson for President Obama said that the policy in regard to who should receive a letter of condolence is currently undergoing a review.

What is Going on Here?

I heard one report state that many soldiers would feel that their comrades combat death would be somehow demeaned if the families of soldiers who suicided were given an equal letter of condolence. Another view is that treating suicide the same as other war deaths might encourage mentally frail soldiers to take their lives by making the act seem honorable. These ideas may be influencing the thinking of some our military leaders and perhaps the President. I hope not.

If this is the case it is misguided thinking which resurrects the stigmatization of mental illness. These conditions are not something that anyone chooses to have. This includes depression, post traumatic stress disorder and traumatic brain injury all of which can be secondary to combat experiences. Soldiers cannot will themselves to avoid these conditions anymore than a soldier can avoid a bullet aimed at their head or an explosive device that goes off under their vehicle.  While training and good support can reduce the odds somewhat but once you are in a combat zone you are vulnerable to injury. I also know of no evidence that people on the verge of suicide would be driven to do it because their family would get a letter of condolence.

There is a famous cartoon which shows a therapist giving a patient a large slap in the face while saying “Snap out of it”  and the title of the cartoon is “One Session Therapy”. If there is humor in this, it is because some people have the phantasy that it is that easy to put aside psychological injury. Anyone with knowledge about mental illness and clinical experience knows that it is not true.

A soldier who suffers to the point of  ending his or her own life, has to be recognized as someone who has suffered as much as anyone can imagine.

As far as the idea that some deaths deserve a letter of condolence and some don’t, consider this. If a soldier in Iraq is working in the kitchen and the stove catches fire leading to his demise, would this death be any less deserving of a letter of condolence than a soldier who was caught in an enemy ambush? Would the loss be any less deserving of the latter soldier if it turned out that he made a foolish tactical error leading to his being killed as compared to someone who was brave enough to fall on a grenade to save others lives? Of course not. Similarly, would you compare a soldier who faced many horrific combat situations and developed PTSD with another soldier who became severely depressed shortly after his  plane just  touched down in the combat zone if both ended up having intolerable suicidal feelings which led to their death? Would one family be deserving of a letter of condolence and another not? I don’t believe that we judge some soldiers deaths as being more worthy than others.

Yes, we do give out special medals and recognition  for unusual acts of bravery but these in no way diminish the sacrifice that others have made.

They Are All Heroes

All of the soldiers that we have discussed above would have volunteered to serve in the military and today everyone knows that this most likely could mean exposure to combat. For this they deserve our thanks and when they and their families have made the supreme sacrifice they deserve at least a letter of condolence.

Action to Fix This Situation

What can we do to see that the families of soldiers who have suicided be given the same letter of condolence as families of other soldiers who have died in the military?

We can a write a letter to the President of the United States, Secretary of Defense and our Congressperson and US Senator. Those of you who are mental health professionals should clearly state this in such correspondence and explain how you feel about this situation especially based on your understanding of mental illness. The email address to write to the President is :       president@whitehouse.gov       There is every indication your email would be read by his staff and a sample of them are often shown to the President.  If many of the readers of this blog were to write him a note it is bound to make an impression as this issue is under consideration by the President at present. If you would like some tips on how to write to the President I found this brief article .

We should also ask our professional organizations if they have not done so already to weigh in on this matter. I am writing a letter to my colleague Dr. Alan Schatzberg, President of the American Psychiatric Association (APA), requesting him to consider asking the Board of Trustees to pass such a resolution if this has already not been done. This last November I finished my term as Past Speaker of the Assembly of the American Psychiatric Association and left the Assembly. So while I cannot sponsor such a resolution myself anymore,  I will ask my former colleagues there to also consider doing so . Both the Board of Trustees and the Assembly must approve position statements in the APA. I would hope that once this organization takes it on they will be able enlist the support of our colleagues in the American Medical Association as well as other professional groups.

By all indications President Obama is a compassionate person and I believe that once he has the facts and has heard from the public including mental health professionals, he will do the right thing.

I welcome your comments on this issue.

About year ago we took a family vacation in San Francisco and I walked across the Golden Gate Bridge with my granddaughter who was just becoming an avid reader. At various intervals on the walk we encountered a  suicide hotline telephone and a sign which said There is Hope. Make the Call. The Consequences of Jumping From This Bridge are Fatal and Tragic. This put me in the difficult position of trying to explain to a seven year girl why people might want to kill themselves and why do they choose this bridge to do it.

I first encountered this special characteristic of this beautiful bridge during my rotating internship at San Francisco General Hospital  when I had the opportunity to examine would-be jumpers who were brought to the ER or to the Psychiatric Service. An update on knowledge known about this subject, some of which I will discuss in this blog, just came out in the October 2009 issue of the American Journal of Psychiatry in an article titled Suicide From the Golden Gate Bridge by Drs. Mel Blaustein and Anne Fleming.

It Wasn’t Suppose to be A Place For Suicide

In 1936, Chief Engineer Joseph Strauss wrote, The Golden Gate Bridge is practically suicide proof. Suicide from the bridge is neither possible nor probable. It turned out however that the Golden Gate Bridge is the most popular suicide site in the world. By 2008 it was calculated the number of suicidal deaths form this bridge was close to 2000.

The bridge is really quite an accessible site to someone determined to use it for suicide. It has a pedestrian walk, a four-foot railing, a bus stop and a parking lot.

What is the Attraction of This Bridge For Suicide?

It certainly is a beautiful bridge offering breathtaking views of San Francisco, Oakland, Berkeley, Alcatraz and the San Francisco-Oakland Bay Bridge as well as the Pacific Ocean. There is often a morning and evening mist. It may be the most photographed man-made structure in the world.

Between 2005 and 2008 Dr. Blaustein interviewed 63 people who had threatened to go to the bridge to commit suicide. 49 of them were male with a mean age of 38. The reasons that they gave for selecting the bridge included accessible/easy (N=36), romantic (N=15), painless (N=6), other reason (N=16). It is quite doubtful that it is painless. Jumpers fall over 200 feet and hit the water in 4 seconds at 75 mph. They die from massive injuries to the chest, heart, central nervous system (spine and brain) or by drowning. The fatality rate is 99%. One report of an interview of 6 of the survivors revealed that all of them said that their suicide plans involved only the Golden Gate Bridge.

People who commit suicide from the Golden Gate Bridge do not have a greater degree of mental illness than suicides in general. 40 % were under psychiatric care at the time of their deaths. 22% had made prior attempts and 25% had left suicide notes. The majority of them were believed to have been employed. Suicide jumpers at the Golden Gate Bridge according to the Blaustein & Flemming article come from all walks of life including a county medical society president, a pastor of a Lutheran church, a president of the Oakland Real Estate Board, the founder of Victoria’s Secret and the son of President Kennedy’s press secretary.

I use to think that San Francisco was a magnet for people from all over with problems and those who wanted a try a new lease on life. I had thought that perhaps suicide from the bridge might be more likely to occur in those who came there and still couldn’t deal with their problems. However it turns out that mostly local residents commit bridge suicides.  Only 5% of jumpers between 1995-2005 were non-Californians. Apparently there are similar statistics at Niagara Falls where during one time period the 141 people who committed suicide lived within a 10-mile radius of the Falls.

Will a Special Barrier at the Bridge Prevent Suicides?

Many people have wanted a barrier to be built at the Golden Gate Bridge to prevent people from jumping off the bridge. Barriers have been shown to reduce suicides at a given location. Barriers at the Eiffel tower, Empire State Building and the Harbor Bridge in Sydney, Australia have virtually eliminated suicides at these locations. However, clinicians have known that if people are determined to kill themselves, there is no foolproof method of stopping them from eventually carrying out this desire.

That being said, many studies have shown that reducing a lethal means can reduce suicide statistics. When non-lethal gas was substituted for coal gas, which was previously known to be the cause of 1/3 of suicides in England, the suicide rate fell 25%.  Building a suicidal barrier at the Duke Ellington Bridge in Washington D.C. reduced the number of suicides in a seven year period from twenty-three to one. The suicide rate from the nearby Taft bridge that doesn’t have a suicide barrier did not increase Similar examples are sited from Augusta, Maine, Bern, Switzerland and Bristol, England.

One study examined 515 people who were restrained by police or bridge workers from jumping off the Golden Gate Bridge between 1937-1971. As of 1978 94% either were still alive or had died of natural causes. Only 6 % were believed to have subsequently committed suicide.

Blaustein and Flemming in their excellent article offer some suggestions as to how a barrier at the Golden Gate Bridge might work to prevent suicide beside the obvious one of blocking access to a lethal method of killing oneself. They note that even if people were diverted to another method to attempt suicide, it is likely that such a method would be less lethal. They also discuss the theory that suicidal individuals may interpret a barrier as a “sign of care” and possibly reduce their despair. Finally they speculate that certain sites such as the Golden Gate Bridge may become suicide magnets and may even catalyze or amplify suicidal feeling in vulnerable individuals therefore a barrier at such a site could be effective in reducing suicides.

In October 2008 an effort by many organizations led by the Psychiatric Foundation of Northern California was successful in getting the Golden Gate Bridge Board to approve the construction of a suicide barrier. Environmental studies and a funding plan need to now be developed before it can be built.

Understanding Suicidal Behavior and Preventing It

Psychiatrists and other mental health professionals have been studying suicide for many years with the hope that the more we understand it, the better that we will be in treating suicidal people and preventing suicide. We believe that the treatment of depression with medication, psychotherapy and often in combination is probably one of the more effective deterrents to suicide.

Research has shown that there are biochemical differences in various parts of the brain in people who become suicidal. There also has been evidence that higher levels of impulsive aggression in individual as well as a family history of suicidal behavior appear to be predictors of suicidal behavior in individuals. These characteristics are not simply explained by the presence of depression. It also has been shown that a history of childhood sexual abuse can be associated with subsequent suicidal behavior as an adult.

Do Ask and Do Tell !

Mental Health professionals know that one of the best methods of determining if someone might be suicidal is to ask them. It is a misconception that when a caring person inquires about suicidal thoughts, this will somehow give a person this idea or intensify any such tendency. Much more likely, the presence of someone who cares enough to ask them will make it possible to get that person to accept help.

We know that people who are depressed do come out of this bleak mood. Not only does the support of others make a difference but also treatment for depression does work. This is why the irreversible act of suicide is all the more tragic. Perhaps this is best illustrated by the words of one of the few people who survived a jump off the Golden Gate Bridge as reported by Blaustein and Flemming in the American Journal of Psychiatry.

I just looked out over the water to the city and it was beautiful. I felt that this was the right time and place to kill myself. The last thing I saw leave the bridge was my hands. It was at that time that I realized what a stupid thing I was doing and there was nothing I could do but fall. The next things I knew I was in the water hoping that someone would save me saying, “Please God, save me, somebody save me.” It was incredible how quickly I had decided that I wanted to live once I realized everything that I was going to lose, my wife, my daughter, the rest of my family.

This man is currently in his 30th year of marriage. He is a high school teacher and part time coach. His daughter is an elementary school teacher.

Your comments are welcome.

New York Times Front Page Article About Depression and Suicide in the Military Goes too Far by Publishing Confidential Mental Health Records

After Combat, Victims of an Inner War by Erica Goode was an outstanding front page description of depression and suicide in the military in the NY Times on Sunday August 2, 2009. It focused on the background and circumstances of the suicide of Sgt. Jacob Blaylock who was one of four soldiers of a 175 person military unit who ended their own lives. It used his case history to humanize the complicated issues involved in screening for mental health problems and providing treatment for military personnel who need it. Ms Goode gathered information from many sources including friends, families, fellow soldiers, and records of military service as well as treatment records in the veterans health system. However, I question whether this article, as written, should have been published as it has obviously included publication of confidential mental health records.

The article states that veterans agency records obtained by the New York Times reported that Sergeant Blaylock was hospitalized for depression during a previous tour of duty. It quotes from mental health records from a veterans affairs medical center that he had told an intake counselor that he was experiencing ” sleep problems”, “excessive worry and anxiety,” “recurrent thoughts of death ” and other symptoms. It states that he answered” yes” to all four screening questions for post-traumatic stress disorder” and goes on to describe the content of what appears to have been a therapy session. There are other examples in the article of how the patient responded to being evaluated for suicidal ideation as well as a description of the psychotropic medications which were prescribed for him. Ironically, this is followed by a statement from a spokeswoman for the veterans agency noting that it could not legally comment on specific cases without family authorizations which would seem to indicate that the surviving family did not provide the medical records which they may have obtained. Even if they had, this would be a questionable journalistic approach.

The New York Times owes the mental health community and the public at large an explanation as to the ethical standards that it uses

The delineation of the difficulty in predicting suicidal behavior, the need for more research and continued development of screening and treatment programs can be a worthy outcome of the publication of this article. On the other hand the exposing of confidential medical records may very well make potential patients of the military and veterans system hesitate to seek care as the word gets out that their records can end up in the hands of the press. I believe that the New York Times owes the mental health community and the public at large an explanation as to the ethical standards that it uses in situations such as this one.

I sent my above comments to the NY Times as a letter to the editor and as an inquiry to the public editor who solicits concerns about the paper’s journalistic integrity. As of this date I have not received any acknowledgment or reply.

This blog however gives me the opportunity to raise this issue with my colleagues in the mental health profession and all interested parties. Even in the pursuit of a worthwhile goal of improving mental health services and preventing future suicides, was it necessary to obtain confidential medical records of this nature and display it on the front page of one of the leading newspaper in the country? Could not the same effect have been achieved by printing the interviews with the various parties and conveying the dramatic and sad story without resorting to this last step? If there are no journalistic standards or ethics in this regard, does this mean that any medical records that a reporter can get his or her hands on are fair game for publication if the reporter and the editor feel the story is worthwhile? Or is up to their judgment as to what part of the record can be published? If this becomes the standard of our leading newspapers, I hope that this will not erode the confidence and trust that is necessary for psychiatric patients to have in the professionals who care for them and in the hospitals where it sometimes becomes necessary for them to be admitted.

I welcome your comments on this subject.