Fall Conference Recap

Summary of Presentations
October 20, 2007

Dr Sood presented “Virginia Tech: Lessons Learned and Implications for Public for a Rational Policy”. She discussed her role as a panel member and mental health expert on the Governor’s Panel investigating the Virginia Tech Tragedy. The event occurred on April 16 th and the panel was named three days later. She noted the freedom of information act limited members from gathering in groups greater than 2, because the media would need to be present if three or more convened. She observed the panel was under significant scrutiny with statements in the public eye from the very beginning. The Governor limited the scope of the inquiry to the case, not issues in the Mental Health System. She commented that the members had earned the confidence of the governor and were able to collaborate, despite being independent thinkers. Members conducted many first person interviews to gather accurate data, while avoiding hearsay evidence. She noted the time commitment came at a cost for a practicing physician. Nonetheless, to represent Psychiatry well she talked to experts around the country and made a commitment to remain neutral and separate from a personal agenda. The two major issues were mental illness and commitment law. Another important issue was diversity, understanding that the individual at the center of the event was an immigrant from South Korea. Jerald Kay, Chair of the American Psychiatric Association’s College Mental Health Committee addressed the panel and helped focus the panel on overcoming barriers to receiving medical records. After one month, legal intervention led to the release of records by Executive Order. To complete the report, the panel began meeting twice a week. During the deliberations, Gun Control emerged as a secondary issue. She addressed the role of the media in feeding speculation and misinformation. The panel had to check over 1100 pages of documents and check facts for accuracy. She noted the most difficult days involved interviewing grieving survivors. Her most difficult work was tying up the loose ends, by advocating for ways to close the gaps in the Mental Health System. After the report was published, she was pleased by feedback that the report fairly addressed areas requiring attention of the legislature.

Regarding Seung Hui Cho, Dr. Sood reviewed his life from pregnancy to the end of his life. She noted that he was a sickly child, who had a heart murmur and aversion to touch. The family mental health history included a relative committing suicide. Cho was born in 1984 and the family moved to the US when he was a school boy. In Middle School, he was seen as very withdrawn. His parents encouraged him to be involved in the community; however, he did not participate in sports or clubs. He did go to the multi-cultural family center for counseling and benefited from consultation with a Hispanic therapist. Therapists noted that after the Columbine shootings, his mood grew dark. In his English class, his teacher called his family to discuss his writings about Columbine themes. Referral to a fellow at Georgetown, led to treatment for Selective Mutism using an SSRI. The medication was stopped after he showed sustained improvement. As he prepared to graduate, he voiced interest in attending Virginia Tech. His treatment team recommended going to a campus located in Fairfax County, where his support system was located.

Dr Sood remarked that during his freshman year, his parents visited every weekend. After the first semester, the visits from parents dropped off. For the second year, he moved off campus to share an apartment with an older Chinese student. As a sophomore, he contemplated changing his major from technical studies to English. In the Spring of his sophomore year, he was described as constantly tapping out stories at his computer. These stories were fantasy based. He was a solitary individual, who was making good grades and coming home at every break. Between his sophomore year and junior year, his manuscripts were rejected by publishers. In his junior year, attendance dropped off, as girls voiced discomfort with Cho taking pictures of female classmates with his cell phones. His writings turned graphically violent. Friends in the dorm stopped inviting to eat with them, because he would bring out a large knife and make stabbing movements. The girls who complained of stalking behavior, never made a formal complaint, beyond telling professors.

No educator referred him to the Cook Counseling Center. Judicial affairs at the University, never received a complaint about his threatening behavior. She noted civil complaints by female students were founded, but on campus they were dismissed. Even after the English Department professor wrote to the Associate Dean and the Assistant Director of Judicial Affairs, no action was taken. A father of a girl, who had felt threatened by Cho, spoke to the VT Police Department and campus police interviewed Cho in December. Cho reportedly told his roommate that he was thinking about suicide via text message. On December 14 th, he was referred to St Albans and diagnosed with Mood Disorder, unspecified. The next day, a 15 minute evaluation with no corroborating data yielded the conclusion he did not meet involuntary commitment criteria. The Psychiatrist later stated privacy laws prevented the gathering of data. Other problems included “thread bare” mental health resources at the University and a dearth of outpatient providers in either the private or public sector.

Dr. Sood noted the collateral data provided a basis for making good decisions, not the mental status at the time of the commitment hearing. The foundation of a good formulation was data that had been corroborated by external sources’ such as police, roommates and family. No attempt was made to contact his parents. The Cook Counseling Center did not accept Cho as an involuntary patient. Nonetheless, Cho did make an appointment. At the appointment, nothing was done therapeutically- only demographic information was collected. The discharge narrative summary was sent in January, but was not found in his medical record at the Cook Counseling Center. There was confusion over who would follow Cho and failure to follow through with his treatment plan. No CARE committee was involved. No one knew at Tech. that he had been committed to St Albans and his family did not know. In the spring of 2007, Cho amassed ammo and firearms. On interview, his parents indicated that had they known the situation, they would have removed their son from school and taken him to treatment.

Commitment Law emphasizes “imminent danger”, not “significant risk”. The committee noted Virginia has the most restrictive commitment law. Emergency physicians should be able to offer TDO’s for 8 hours not 4 hours, with a 48 hour limit to hold after TDO. She cited Elizabeth McGarvey’s study indicating “Eighty percent of Professionals and family stakeholders were uniformly frustrated with Virginia’s Commitment laws”. She noted independent evaluations, ie, prescreeners, receive 75 dollars an hour and the task requires much more time to gather data and verify it as reliable. HIPAA and FERPA impacted data gathering by creating barriers against the flow of information. Interface with law enforcement should allow police to “connect the dot’s in order to safeguard the public. Overall, there was lack of short term crisis intervention with adequate follow through to ensure effective treatment.

Specific recommendations included amending the code to allow more time for evaluation and a safe harbor must be created to allow sharing of information with the intention to save life and improve the safety of the community. Universities must be able to assist students without excessive worry about consequences of violating privacy rules. Virginia Health Record Privacy Statutes must be clarified to authorize treatment entities to report noncompliance with mandated treatment. All communities ought to have comprehensive mental Health assessments. Exceptions for HIPPA include overrides to render care. The Family Educational Rights and Privacy Act or Buckley Amendment applies only to federally funded schools, not private school. FERPA only applies to educational records, not personal observations, which may be freely disclosed to parents or practitioners. Your student medical record does fall under FERPA, but it does not include campus police records. An exception to FERPA is release to parents, who claim their student as a dependent. Also, under FERPA parents may be contacted when a health or safety emergency exists or when underage violations regarding alcohol or substance abuse are found. Disclosure to law enforcement was allowed to address safety issues. Information about detention hearings and transportation was not protected, but public information. Over interpretation of the law led to over caution to avoid violation of rules. Use of discretion to meet the intent of the rules must be applied to prevent future loss of life. Finally, Dr. Sood called all of us to advocate for patients and speak the truth in the public arena, based on logic and fact.

Dr. Reinhard presented “Violence, Mental Illness and Public Safety”. He started off by citing three studies from the Archives of General Psychiatry from the last 10 years. The first study, the McArthur Foundation research, involved 1,136 patients discharged from hospitals at three sites. Mental illness without substance abuse was associated with an 18% rate of violence. Substance Abuse alone was associated with a rate of 22%. Patients with both major mental illness and substance abuse completed violent acts at a rate of 44%. Violence was directed primarily toward family members, for both discharged patients and the community sample living in the same neighborhood, not using substances. A higher number of patients used substances compared to the community sample.

A cohort study in New Zealand followed persons born in 1972 until they turned 21. The team learned a psychiatric disorder was associated with an 18% risk compared to 3.8% for no disorder. Alcohol disorder was a associated with a 25% rate of violence, compared to control substances. In the sample, 20% of subjects committed half of the violent acts. Violence in alcohol dependent individuals was best explained by alcohol use before the offense. However, violence in marijuana dependent patients was best explained by a developmental history of conduct disorder, not recent use.

Another study discriminated between minor and major violence among patients with Schizophrenia. Serious violence was found at 3.6% for Schizophrenic patient, with a rate of 19 % of violence overall. Positive psychotic symptoms were associated with risk of minor and serious violence. Negative psychotic symptoms appeared to lower risk. Minor violence was associated with co-occurring substance abuse.

He highlighted an editorial published in the2006 issue of NEJM, which published data showing 68 assaults (nonfatal job related violent act /1000 hours of Psychiatric work. The editorial sent the message that substance abuse contributed much more to the risk of violence than serious mental illness, which has a documented attributed risk of 3-5%. Thus the substance abuse history is a better predictor of violence than perception of threat by the patient. Nevertheless, medical practitioners must take necessary precautions when treating the mentally ill. Most mentally ill are the recipients of violence, not perpetrators of violence.

Dr Reinhard focused on two Tech Panel recommendations. The Panel had 24 total recommendations. Number 12 noted the state should study outpatient services. Dr Reinhard commented that Virginia opened the first public health hospital in the US in 1773, then funded community service boards in 1971 to emphasize the point there was a long history of providing inpatient services and a short history of providing outpatient services. The most recent study was the 2006 Chief Justice report on Mental Health Law.

In Virginia, there were 16 facilities and 40 community service boards. The inpatient bed shortage was noted to include licensed state beds and private sector beds.

An increasing number of beds were occupied by Forensic patients. A lack of a collaborative approach coupled with utilization review has led to inefficient use of state beds. There are 1500 state mental health beds at present, compared to 12,000 beds in 1968. He noted that California had solely Forensic beds, no beds for acute stabilization. He commented the vision for community health was not fully realized, as patients have been trans-institutionalized to the jail systems. There were now 24,000 in jail. Sixteen percent have mental illness. Only about 1,800 are in jail with serious mental illness.

The biggest factor of people getting better, but not well is the mainstreaming of psychiatry to include social security disability and Medicaid coverage. Funding by the same sources as other medical conditions are bringing our patients into the mainstream so the receive not just medical services, but also housing. CSB’s are billing Medicaid to a greater degree and relying on state funding to a lesser degree. Few states spend more per capital on facilities for inpatient care than Virginia does. The national average spent on state psychiatric inpatient coverage was $150 million, while Virginia spent twice as much. Virginia ranks at the bottom for community mental health expenditures.

Criteria for involuntary commitment in Virginia Code 37-2.817 (B) should be modified in order to promote more consistent application of the standard to allow involuntary treatment in a broader range of cases. The code does not address noncompliance with court ordered outpatient treatment. Dr. Reinhard anticipated that Kendra’s Law in NY will most likely serve as the model. Three types of Mandatory Outpatient Treatment included conditional release, Alternative to Hospitalization (what we have in Virginia) and Need for Treatment (Kendra’s Law).

Before Kendra’s Law, the Bellvue Study looked at similar groups, one with a court order the other without showed similar outcomes. A study conducted at Duke showed the opposite, supporting intensive outpatient treatment as keeping patients out of the hospital longer. Current studies are trying to answer the question; does a court order enhance treatment? In NY State, a parallel system monitors court ordered care, through enhanced community services. His message to the General Assemby has been incremental tweaks will not help. He concluded with a quote from Paul Applebaum, we are witnessing an unprecedented wave of interest in outpatient commitment…” due to violent acts in the headlines, however, the reason to provide involuntary outpatient care is to ensure good care to our patients.

“Disaster Mental Health: an Overview and Update in Virginia” was presented by Dorinda Miller, PhD and our own Ed Kantor, MD. Dr. Kantor emphasized the importance of collaboration in disaster related activities. Disaster Mental Health was described, then critical incident stress management was contrasted with psychological first aid. Dr. Miller implored physicians to leave their families and facilities prepared for a disaster, so they are free to leave and assist. She noted in the event of a disaster, your dog may be missing, your car may be un-drivable and your roads may be impassable. A disaster event was defined as a traumatic event that overwhelms the community. A crisis is defined by the individual, while the disaster is defined by the community. All events start at the local level. Disaster mental health does not involve diagnosis or treatment.

First order intervention includes peer, lay and paraprofessionals greeting and triaging persons coming for help. Hydrating persons under stress and protecting them from media are basic tasks, meaning as a doctor you may be assigned to hand out bottled water. A second order intervention includes professionals presenting symptoms of a disorder or existing condition. Multi-modal approaches include supportive and cognitive approaches. Detoxification for substances of abuse, such as people receiving methadone treatment, may be required. Medications for sleep may be prescribed. The basic job is to impose order in the middle of chaos. Providing snacks, water and toileting facilities bring order, for instance. The mental health response should be integrated with the whole recovery process as opposed to highlighted as something to invoke for severe reactions.

Citizens should be encouraged return to normal activity, following a disaster. Extreme reactions, such as feelings of hopelessness or self-harm, should be looked for by outreach workers. These workers were assigned to places such as bars in the affected neighborhood. Existing social structures can be used to reach the affected. Sensitize workers to groups, who may be turned into villains.

Dr. Kantor focused on Eye Movement Desensitization and Reprocessing, as an early mental health intervention noting data indicated it should not be a routine part of the disaster response. Psychological debriefing may cause harm with “systemic ventilation of feelings” as the potentially most harmful phase. The term debriefing should only be used to describe operational debriefings, which are done for reasons other than treatment or prevention. A new approach with an operational focus and intent is “decompression”.

Decompression allows persons to get the big picture and share their individual experience, while asking how the disaster response could be better. The intent is to use it as a quality improvement tool in disaster response.

People do not respond to crisis uniformly or grieve uniformly. Many practices that may have captured public interest have not been proven effective and some may do harm such as massage of persons who feel violated by touch.

Psychological First Aid is an evidence informed modular approach to assist children, adolescents, adults and family in the immediate aftermath of a disaster or terrorism. It is designed to reduce initial distress caused by traumatic events. It fosters short and long term adaptive functioning and coping. Given that few people have gotten through difficult times in their lives, so they are asked to tap into their own resilience. Plans need to be situationally based and attuned to developmentally and culturally appropriate interventions for survivors of various age groups. For example, workers should understand putting a hand on another’s wheelchair violates that person’s personal space.

The Field Operational Guide for the Medical Reserve Corps was available on-line from the National PTSD Center. Many components have been tested and validated. Two federal granting programs are through the Universities of OK and VT. Dr Kantor was willing to connect researchers in Disaster Health with funding sources. Components include:

• Contact and engagement
• Safety and comfort
• Stabilization
• Information gathering
• Practical assistance
• Connection with social supports, etc

Support teams connect survivors as soon as possible to social support providers, including family, friends and community helping resources.

CSB are lead disaster mental health agencies in state and federally declared disasters. The Red Cross is the lead disaster mental health agency in transportation disasters. Red Cross should coordinate with lead agency and other players. Dr Kantor noted mental health training for disaster was available through the Red Cross, the Dept of Health and Human Services and SAMSHA. Courses were available at NY Stat University of Nebraska and University of Rochester, as well as the Commonwealth of Virginia. The Univ. of Florida offered training in rural mental health. The APA offers courses at the Spring National Meeting. Dr Kantor encouraged interested physicians to affiliate with local agencies integrated into the local disaster response plan or join the Medical Reserve Corps.

Dr Vieweg presented, “Neurobiology of PTSD”. He noted from an evolutionary perspective, key tasks included selection of a mate, bearing of viable offspring, parental commitment to sustain offspring, plus threat detection and response inhibition to enhance survival. PTSD is only one type of response to a traumatic event. Depression and anxiety are other responses. Dr Vieweg compared Acute Stress Disorder with PTSD.

Neurological responses included a heightened response from the Amygdala(emotional dysregulation). The Medial Prefrontal Cortex was low functioning during symptoms. Other key anatomical structures were the anterior cingulated cortex (impulsivity), corpus callosum, hippocampus, hypothalamus, prefrontal cortex, pituitary and thalamus. Different structures with anatomic dispersion are disrupted. In particular, cognitive peceual impairment is related to disturbances in the dorsolateral prefrontal cortex (executive functioning).

PTSD plays out with re-experiencing, avoidance/numbing and hyperarousal, demonstrating a maladaptive reaction to severe stress. Prior labels included War Neurosis, Combat Fatigue and Shell Shock. Short cuts from the sensory relay thalamus to the Amygdala occur during times of danger, providing direct access to the fear structures of the Central Nervous System. This allows the person to take action prior to conscious awareness. In other words, before you know you are afraid, you are responding to danger. Only after fear activation does conscious mind kick in and permit reflection of the situation. In PTSD, the person is in a prolonged state of alert.

In PTSD, problems in learning, acquisition of information, coding of data, retrieval of memory and consolidation of lessons learned are commonly seen. Overall, the initial event is distorted in the life of the patients. Unconscious memory and declarative memory were discussed with further explanation of episodic, semantic, procedural (nondelarative) and working memory. On the surface of the brain, the inferotemporal lobes were intimately involved in semantic and working memory.

Dr Vieweg noted long term potentiation is a mechanism for changing synaptic weights to strengthen memories (known as Hebb’s rule of learning). Information reinforced by repetition is gradually learned. Glutamate is the principal neurotransmitter released during learning. Initial learning takes place in the hippocampus and LTP is the principal mechanism by which we remember and learn. The Amygdala modulates aspects of emotional memory storage and modulation of memory related activity in the hippocampus.

The dual branch hypothesis of PTSD combines classical conditioning with operant conditioning. Aversive encounters lead to simultaneous formation of associative memories involving both classical and operational learning. Dr Vieweg noted that many different ways exist to develop traumatic stress disorders. Concussion or TBI results from rotational motion of cerebral hemispheres in anterior posterior planes, around the fixed brain stem, which acts as a fulcrum. Blast injuries kill fewer soldiers due to body armor, but the brain was not protected as well as internal organs. Complex pressure waves cause shearing of synaptic connections. Potential mechanisms of injury by the overpressurization wave include biomechanical, hemodynamic, and neurobiologic (diffuse axonal injury).

Components of vulnerability are preexisting factors that are psychological or biological. Allostasis is the process by which our bodies maintain stability. Allostasis includes other systems changing to maintain homeostasis. Maintenance of allostatic changes over a long period of time may result in allostatic load. Body systems will wear out if not rescued in time. So allostasis is the capacity to achieve stability through change. Four major factors are genetics, development, early adult experiences; state of neurobehavioral systems; midlife issues of employment and family change; and finally, memories of ourselves and our world before the trauma.

Dr Vieweg reviewed medications being studied for use with cognitive or behavioral treatment. Both Paxil and Zoloft are approved for the management of PTSD. Resiliency factors include optimism, self-sufficiency, lack of cognitive impairment coupled with a strong set of beliefs. In summary, PTSD was described as a recovery failure from a universal set of emotions associated with danger or threat.

Submitted by;

Steve Brasington, MD, DFAPA
President PSV