Everything You Wanted To Know About Psychiatry In 30 minutes or Less....

 

It has been a week since I gave a presentation to the Philolectian Society in Anoka, Minnesota.  The Philolectians are primarily retired educators and their colleagues who decided they wanted to promote education in their county. They do this by topical discussions on a monthly basis and fund raising for scholarships that they award to high school students.  They were founded 134 years ago.  I gave them a presentation on substance use disorders about 5 years ago – but my current presentation was entitled “Everything You Wanted To Know About Psychiatry In 30 Minutes of Less.”  It was the mile high view – but that is the one that is typically lacking in American culture.

The venue was a sports bar conference room in an old building. There was no projection equipment and it had spotty WiFi coverage so I decided I should test it out ahead of time. I opted to use a Chromecast device to the television HDMI port – but did not realize at the time that it does require WiFi in order to work.  Connection to my home TVs was not a problem but there is continuous WiFi as the background.  Failing the Chromecast, I was given an LED projector that also required WiFi. I ended up printing out hand outs for the attendees. The 12 slides follow and total time was about 45 minutes – 30 minutes of presentation and a 15 minute Q & A.  My presentation style is to focus on slide design.  For that reason I avoid the standard templates and try to cover as much of the slide with graphics as possible when they are used.  My second overall principle is to free associate to the slides and never read them. They are there to keep me on track.  What I actually end up saying varies considerably from lecture to lecture – modifiable by various factors including what the group has indicated what they want to hear, what I have been thinking about that day, and what I have been reding that week. The process is like Frank Zappa described his guitar playing. Every live performance is unique – no set of notes is identical.  I can’t claim mastering lectures like he mastered the guitar but there is some creative process involved in lecturing.

The title slide uses a background of abstract art taken off of one of my paintings at home. The artist is Stephen Capiz.  It represents a very small area of a larger abstract painting with the tile information superimposed. The title was chosen to keep the atmosphere casual. I wanted people to be comfortable that this was not a presentation to mental health professionals but to a general audience.

Slide number 2 is a critical three - fold message that is frequently missed or distorted.  Psychiatric disorders have been observed and discussed since ancient times.  That means they are easily recognizable to people with no training. It means that they are real and can’t be explained away.  You must be incredibly naïve or sheltered to not have that experience.  Psychiatrists only exist because they were the doctors interested in treating these disorders. That is as true today as it was in the 18^th and 19^th century.  The only difference is that modern psychiatrists have uniform training. And finally as you would expect, the diagnostic system has undergone successive refinement over the centuries.  The DSM is used as an example here but the ICD could be used as well. (with all slides click on them to expand and get a better quality graphic - this is apparently an artifact of the blogger format).

 

Slide 3  provides a little more detail on the evolution of the DSM systems. Counting the total diagnoses is always a point for rhetorical digressions.  I finally figured out how to do it and listed my specific technique in this post.  To a professional audience, I might include studies on how many of the diagnoses are actually used.  This audience did not find any of this controversial.

Slide 4 is a great timeline of how psychiatry developed from a discipline that Kendler refers to as protopsychiatry to the modern era starting in about 1920 in the US and about 40 years earlier in Europe.  The audience was extremely interested in the low percentage of physicians attending medical schools in 1900 and that lectures could be attended by purchasing tickets. The transition from asylum doctors with no particular training to psychiatrists was also a focal point.

Slide 5 was necessary because there is still a lot of emphasis on Freud. I remembered that Freud was an important figure to my college English professors and that some of the teachers in the audience were about that age. I emphasized that Freud was an important figure in psychoanalysis, but that there were many European psychiatrists that provided knowledge, literature, and training to their American counterparts and that many were self-taught and active across the fields of psychiatry, neurology, neuropathology, and neuropsychiatry.

Slide 6 is a very brief outline of the basic educational milestones of the various mental health disciplines.  Minnesota has a confusing array of designations including unlicensed mental health practitioners so I kept it simple.  In the previous slide on the psychiatry timeline I did mention how in the early 20^th century most practitioners considered themselves neuropsychiatrists and practiced both neurology and psychiatry. When the American board of Psychiatry and Neurology informed practitioners that they would need to take board exams in both psychiatry and neurology the era of separate specialties was begun.

Slide 7 is one of my favorite graphics.  It is produced from the current educational requirements for residency training and Melissa Farmer, PhD greatly assisted me with the graphic design. My overall emphasis was to point out how these training requirements should result in a physician who is not only an expert in diagnosis, but also interviewing, maintaining relationships over time, and capable of therapeutic discussions.

Slide 8 attempts to capture the pattern matching aspects of psychiatric practice and why training and experience are necessary.  It illustrates how previous exposure to various diagnostic and therapeutic elements can lead to problem recognition and resolution.

Slide 9 is a rough sketch of the diagnostic process and how it has to be adapted to the situation.  I provided several examples of referrals that I saw as referrals who needed immediate emergency medical attention.  We discussed how that can occur.

Slide 10 is a list of psychiatric subspeciality care.

Slide 11 is an explanation of the current workforce and how the practice environment has deteriorated over the past 40 years. I emphasized rationing as the main problem and several audience members were aware of the shortage of psychiatric beds and state hospital closures.  The city of Anoka has one of the few remaining state hospitals – Anoka Metro Regional Treatment Center. In the future if I am projecting - this slide would be split to 2 separate slides. 

Slide 12 – I had to leave the audience with a reason why they are exposed to antipsychiatry rhetoric and discussed the basis for it, the special interests involved, and in most cases - the lack of any basis in reality.

The presentation went very well. There was additional interest in the medical and psychiatric effects of the pandemic.  Several audience members were interested in my opinions about the Department of Human Services in Minnesota and how they factor into the current rationed system of care. I am currently expanding some of the graphics in case there is any additional interest and as an outline for some of my other writing.

 

George Dawson, MD, DFAPA

A Confluence of Factors - Why There Is No Functional System of Care for Severe Mental Illnesses

 

 This post was stimulated by a confluence of factors.  I had no real concerns about what I would do in retirement and it seems that I have as much to think about as I did when I was working.  The factors included:

1.  A post by one of my esteemed colleagues on Twitter – Emily Deans, MD.  I have never met Dr. Deans and know her work primarily through her blog, Substack, and Twitter posts.  I cannot recall ever disagreeing with her.  Today she began a thread with: “The US allows people with terrible brain illnesses to languish on the streets and get murdered on the subway.”  She built upon that theme.

2.  I was working on a presentation for Friday May 5 on “Everything You Wanted To Know About Psychiatry in 30 Minutes or Less.”  That got me into a historical frame of mind.

3.  I had the occasion to pick up my copy of Sylvia Nassar’s biography of John Nash “A Beautiful Mind” and reread the description of his civil commitment to a state hospital where he received insulin shock treatments at age 33.

4.  During my work on the presentation I suddenly got the bright idea to create a couple of new timeline graphics – one of which was about European influences on American psychiatry (protopsychiatrists, transitional self-taught psychiatrists, and psychiatrists) and that led to thinking about the current state of psychiatric affairs in the United States.

That all came together to produce the following paragraphs that I have discussed here before but seems reinforced by the current confluence of information.

Psychiatric care in the US is abysmal and it is not due to the lack of bright and highly motivated psychiatrists.  It is due to a lack of access.  It is possible to find those psychiatrists and get treatment but good luck with that.  Dr. Deans is correct that people are currently dying due to the lack of humane laws to treat people with severe mental illnesses. In many jurisdictions those laws are interpreted in the context of the lack of resources.  In other words if there are no facilities available, legal action is dropped. That problem lies squarely on several entities that are far outside of psychiatry. The problem is so chronic it is hard to prioritize which of these entities came first and is the worst (although I have provided a few timelines). Let me take them point by point as they come to mind.

The antipsychiatry movement needs to finally get credit for its destructive nature. Psychiatrists tend to respond either by ignoring them and hoping they will go away or by wasting their time trying to argue against their repetitive rhetoric.  The pandemic and the last election highlighted the use of misinformation in social media. The antipsychiatry movement are experts in misinformation and they have been using the same tactics for the past 50 years.  Part of those tactics include getting their rhetoric and opinions in the mainstream psychiatric literature. In 1986, Martin Roth and Jerome Kroll had the following observation:

“We have argued in this section that the concept of mental illness has definable boundaries and that medical forms of care are appropriate and efficacious only in circumscribable portions of those who present a danger to society. But recent trends if allowed to continue, can only culminate in a society in which prisons again contain a large portion of those who suffer from mental illness because there is no appropriate or alternate form of care or accommodation for them. If such a situation should materialize, the distinction between prison and hospital will become once again blurred and obliterated like it was 133 years ago when Bucknill held out optimistic hopes of a new era in which science and humanity would jointly seek to surmount the problems presented by morbid mental suffering. The hard-won and remarkable progress achieved by psychiatry during the past half century in particular, will then have been set into reverse.” (p. 114).

There has not been a more prophetic statement in the field.  The largest psychiatric hospitals in the United States are currently county jails. The state hospital systems that were in some cases flagships for treatment of people with severe mental illnesses are no longer functional and exist at the margins to alleviate pressure on community hospitals to accept involuntary patients.  It is more of a blockade than a bottleneck since the latter would suggest movement once the obstacles have been passed.  There is no movement and the association of state mental health directors has made it very clear they are not interested in movement.

The basic paradox of the system is that the necessary infrastructure necessary to treat even average numbers of persons with severe mental illnesses and those who are under civil commitment is not there.  It is atrophied or rotten and there has been no wide sustained effort to improve it since The Community Mental Health Act of 1963. Even though the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008 – it is clear to anyone working in the field that there is no enforcement to ensure mental health parity or adequate substance use treatment. The healthcare industry has sent a clear message that it takes more than a law on the books – it takes concerted and very expensive legal action.  In the past some activist attorney generals had some success – but there are not many of them around anymore.

It is not hard to imagine how a fragmented system of care has withered during a time of continuous antipsychiatry rhetoric.  Money is always cited as a limiting factor, but the amount of money especially compared with the ballooning number of administrators at the state and health plan levels does not seem great. State hospitals and departments of human services seem to run on a managed care rationing model rather than a model focused on helping the most vulnerable citizens. It is not a coincidence that both antipsychiatry and business rationing for profit both depend on Libertarian values – the most basic being “you are only worthwhile if you are living what I determine to be a worthwhile life.”  That same value system criminalizes aggression and violence secondary to mental illness and sees incarceration as the only beneficial outcome. That is consistent with the current model of county jails as psychiatric hospitals that do not deliver any psychiatric care.

That brings me to the Nash biography. He was hospitalized in about 1961 at Trenton State Hospital.  According to Harcourt’s graphs of deinstitutionalization – this was the beginning of a time of rapid decline in mental hospitalization rates that has continued unabated to the present time. Trenton was overwhelmed by the large number of patients seeking help there – 4,000 after World War II dropping and then rising again in the 1960s to about 2,500 when Nash was there. Psychiatrist staffing ratios varied from 1:100 patients in the acute ward to 1:500 patients in the chronic ward.  Length of stay for most patients was about 3 months. Rationing clearly existed even before deinstitutionalization. One of the psychiatrists who worked there described the environment as “crummy.”  In terms of personal relationships with patients – it could be expected to be rare with those staffing ratios.  Nasar describes the hospital as “overcrowded, underfunded, and understaffed.”

Figure 1. Rates of Institutionalization in Mental Institutions and State and Federal Prisons (per 100,00 adults) from the paper by Bernard E. Harcourt, " REDUCING MASS INCARCERATION: LESSONS FROM THE DEINSTITUTIONALIZATION OF MENTAL HOSPITALS IN THE 1960s," 9 Ohio St. J. Crim. L. 53 (2011), available at: https://scholarship.law.columbia.edu/faculty_scholarship/639

The exception noted was the insulin unit.  Apparently, Nash was recommended to go to this hospital because it had this modality.  It was a 44-bed unit – half men and half women in separate wards. Patients on that unit received special diets and special recreation.  That is where Nash got insulin treatments 5 days a week for the next 6 weeks. Nash later described the agony of these treatments in detail including what may have been long tern effects on his dietary pattern.  In retrospect, the question is whether it was necessary or not.

Manfred Sakel had discovered insulin shock treatments (IST) in 1935 by accidentally administering too much insulin to a patient with morphine addiction resulting in seizures and a coma.  The patient awoke with more mental clarity.  That led to further trials and wider application. Nassar suggests that by 1960, IST had been phased out in most hospitals and replaced with electroconvulsive therapy (ECT).  Max Fink did a direct study of chlorpromazine versus IST in 1958 (2) and noted that the results clearly favored chlorpromazine.  That resulted in the IST unit at his hospital closing within 6 months (3). Even though Nash had not been able to work for the previous 3 years he was widely regarded and his intelligence was described as a national security asset. As he was recovering, he started a paper on fluid dynamics while he was at Trenton that he subsequently finished and published in 1962 French mathematical journal. He was awarded the Noble Prize in economics for game theory in 1994. His original two page paper at age 22, was part of the basis for the Nobel determination (5,6).    

Nash’s tenure at Trenton is a good example of rationing prior to managed care. The rationing resulted in both the abysmal conditions and a lack of state-of-the-art care. Some might say that you can’t argue with results.  Nash recovered and was able to go back to research and publishing in mathematics, despite his dissatisfaction with treatment.  Later in his biography he was treated with a number of second generation antipsychotic medications that were described as helping him stay out of the hospital but  “have not given him a life.”

That brings me back to Dr. Dean’s comment at the top of this post. We have people with severe mental illness dying on the streets. A small number become aggressive and violent, but a much greater number are victims of violence and exploitation. They do not have stable living situations and there are associated problems with substance use disorders. This is a gross level of neglect compared with way other healthcare problems are addressed requiring more resources than psychiatric care. About 1 in 300 people get retinal detachments during their lifetime. In any mid-sized city in the United States access to state-of-the-art retinal care is not a problem. The same thing is true for orthopedics, gastroenterology, and cardiology. Psychiatric care is fragmented across private pay systems, public pay systems, and managed care systems.  The last two are managed by large bodies of administrators that are focused on rationing rather than an adequate system of care. In many ways, the landscape of psychiatric care is approached with the same level of recklessness as firearms. We all have to pretend that something useful can never be done and therefore maintain the status quo.

 

George Dawson, MD, DFAPA

 

References:

1:  Roth M, Kroll J.  The Reality of Mental Illness.  Cambridge University Press. Cambridge, England 1986: 82-144.

2:  Fink M, Shaw R, Gross GE, Coleman FS. Comparative study of chlorpromazine and insulin coma in therapy of psychosis. J Am Med Assoc. 1958 Apr 12;166(15):1846-50. doi: 10.1001/jama.1958.02990150042009. PMID: 13525160.

3:  Fink M. Meduna and the origins of convulsive therapy. Am J Psychiatry. 1984 Sep;141(9):1034-41. doi: 10.1176/ajp.141.9.1034. PMID: 6147103.

4:  John F. Nash Jr. – Facts. NobelPrize.org. Nobel Prize Outreach AB 2023. Sun. 7 May 2023. https://www.nobelprize.org/prizes/economic-sciences/1994/nash/facts/

5:  Holt CA, Roth AE.  The Nash equilibrium: A perspective.  PNAS. 2004; 101 (12) 3999-4002.  https://www.pnas.org/doi/10.1073/pnas.0308738101

6:  Nash Jr JF. Equilibrium points in n-person games. PNAS. 1950 Jan;36(1):48-9. https://www.pnas.org/doi/full/10.1073/pnas.36.1.48

Graphic Credit:

I took this photo of the Rum River Dam in Anoka, MN about 30 minutes after I gave my presentation on May 5, 2023.  Anoka happens to be where the Anoka Metro Regional Treatment Center is located.  It is the last state mental hospital in Minnesota.  Since 1978 Minnesota has closed 10 of its 11 state hospitals and only AMRTC remains.  There have opened 6 - 16 bed units called  Community Behavioral Health Hospitals that have reduced capacity and apparently do not accept referrals from major metropolitan hospitals. https://mn.gov/dhs/people-we-serve/adults/services/direct-care-treatment/programs-services/community-behavioral-health-hospitals/

Medical Library Access - Revisited

 

It has been 2 years since I posted about the problems with medical library access if you are not faculty or adjunct faculty at your state medical school.  In that previous post I detailed all of the considerations and you can review them in that post. Several of us lost access during some turmoil at the University and my understanding is that we were taken off the necessary status by an interim department head who was not a psychiatrist.  My basic argument is that every physician in the state needs access for quality care purposes and if the medical school was no longer willing to provide that access, I would be happy to purchase it.  I was given a quote of $1,000 per year and let everyone who needed to know that I was willing to pay it. No response from anyone.

Since that original post, I contacted my state representatives. I got the usual “I agree with you and will look into it and get back to you.” But nothing beyond that. Nobody got back to me. Despite a good response from a post to the original nothing else happened.

I joined the University of Minnesota Alumni Association because I was told that would allow some access to the online library but nobody could tell me how much access I would have to the Health Sciences Library (formerly known as the Biomedical Library). I ended up with no access to anything.  Even though I clearly met alumni criteria nobody was ever able to send me what I needed for access.

While all of this was going on – I had to get access where I could. That typically involves an initial Google Scholar search looking for links to full text access in that format. A major online resource that was linked to Google Scholar removed that access last year. The links remained for a while but it was apparent you needed a subscription to access them and it was impossible to apply without a university affiliation. If Google Scholar fails I check Medline (PubMed) to see if full text is available.  Failing that I will go to Research Gate to see if full access is available there. When that does not work I will send an email to the corresponding researcher either on Research Gate or directly to an email address listed in the original paper. I have paid the charge for paywalled research only once, but I did subscribe to the Nature journals package for $30/month. So add $360/year to my previous total for journals access. It is not unusual to find out that you don't really have access to all of the Nature journals that you need. 

Many colleagues with medical library access from across the country volunteered to send me the articles I wanted for whatever I was researching at the time. I am very grateful for those offers – but the practical issue is the amount of reading I do.  It is impractical to ask anyone to provide that level of access unless they are being paid to do it.  The other issue is legality. Every library originated paper even in the electronic format – comes with a legal statement about copyright laws and something to the effect that I am the only end user and it will not be posted in an electronic format or shared with anyone else.  

I also tried county libraries to see if I could get access to medical journals.  Two years ago I applied – and went to their online site and there was nothing.  This year I reapplied for a library card and this time it was linked to a metropolitan county library with digital access to journals. There is a lengthy request form for every article accessed and that form times out quickly and erases all of the data that you entered.  If you can get past that point and the journal is in their database  – you can get a PDF of the requested paper. The turnaround time is 2-3 days and the barriers are such that it keeps the levels of requests low. So far, in the past 6 months I have requested and received about 10 papers.  I am hoping some day that they streamline the process.

That has been the battle for access to technical information on medicine and psychiatry. The county library access was a pleasant upside. The University’s Heath Science Library still looms large. I think the notion of a large taxpayer funded library for health sciences students and trainees that is only available to them when they are students, trainees, or faculty is an antiquated idea. Physicians are trained in lifelong learning.  To accomplish that goal – lifelong access to information is needed. Access is currently given to adjunct uncompensated faculty as a perk and that may be the real reason for not allowing a physician to pay for access. In other words it is a business management strategy. If access is controlled - the service becomes more valuable and it seems like uncompensated adjunct faculty are really getting something for their time.  I doubt that there would be a tremendous increase in utilizing the services even if they were free. It would be much more efficient because it would not require library staff somewhere – to read and decipher all of the requests when the physician could just find the journal and get exactly what they need. If you are reading this from a state other than Minnesota – I am very interested in hearing how you access the medical literature online if you are not medical school staff and do not have a subscription to the journal you want to access.

In the meanwhile – I will keep plugging away at my work arounds.

George Dawson, MD, DFAPA

Success Rates In Psychiatry

 

Today's comment is on a brief editorial in JAMA Psychiatry about the evidence of success of psychiatric treatments (1). The authors present an even handed argument for establishing systems that would allow for the determination of success rates of psychiatric care. They point out the obvious limitations of developing these systems in the United States but may not have gone far enough. In the US - our healthcare data is considered proprietary by the health care company who owns the electronic medical record that the data is recorded in. Patients often find themselves in varying negotiations in order to get access to their own records. They may find some data is not accessible at all. If they venture into another system of care that uses the same electronic health record (EHR) – they may have to repeat significant portions of their record (current medication list, allergy list, immunization record, test results) that should have easily transitioned. Within a typical metropolitan area in the US – there may be many EHRs that cannot communicate with one another at a level that would allow determination of success rates. As a result, the authors conclude most of the success rate data in psychiatry comes from clinical trials.  That data is limited by selection biases and brief periods of treatment.

The authors also look at Specific Success Rates (SSR) and Aggregate Success Rates (ASR) as population-based quality measures. To the best of my knowledge there are no corporations currently using these measures. That lack of usage is based more on medical tradition than usefulness of quality measures. Current hospital and clinical measures typically sample worst possible outcomes or so-called sentinel events. This is the business approach to mortality and morbidity conferences in medicine and surgery that were detailed discussions of deaths and complications. The thinking has typically been to learn from worst case scenarios or your colleagues’ obvious mistakes. The problem with those conferences is that they provide little guidance about the best treatment for most other patients.  For many years Medicare used the same system.  I was a Medicare Quality reviewer for 2 states and their focus was on process rather than outcomes and success rates were never discussed.  Major quality events like a death on a psychiatric unit would trigger a detailed quality review.

As a long time follower of the work of Tiihonen, the first flaw that I noticed was that none of his work was referenced.  Tiihonen has a long track record of looking at outcomes using observational studies (2-12) and has commented on both the limitations and advantages of these studies (17). One of the critical advantages of doing research in Scandinavian countries is access to nationwide databases or registries that include the usual demographic patient information but also diagnoses, treatments, medications and outcome data.  Those data include hard outcomes (suicide, all cause mortality, disability) and soft outcomes (drug discontinuation, rehospitalization, symptom checklists, side effects checklists, psychosocial outcomes).  Similar data is available in other studies such as long acting injectable (LAIs) antipsychotic medications back to the 1980s, treatment cohort studies (Schou, Winokur, Guze, Angst) from similar periods and various sampling studies that look at surveys of medical clinics.  There are also the statistics from the 19^th century protopsychiatry era.  My favorite one is from Luther Bell (15) describing the outcomes of delirious mania:

“A subsequent case series published by Luther Bell in 1849 described 40 patients with the condition among 1700 admissions to McLean Hospital (Bell, 1849). He reported a mortality rate of 75% in these patients."

Today - nobody dies from delirious mania or the more common forms of mania that frequently led to deaths from congestive heart failure during the protopsychiatry era.  That is an improvement in mortality on par with any other medical specialty and it is due to improvements in psychiatric care.

But nothing can replace the rigor and data of registry studies from Scandinavia. By rigor I mean the results of treatment of unselected real-world patients in real world systems of care, very large data sets, and no missing data. Clinical trials can't compare when as many as 80% of real-world patients are omitted from consideration (16) and those patients may be at higher risk for morbidity and mortality outcomes.

Psychiatric treatment success rates are available if you look for them.  I am not as negative about observational or registry studies when I consider the advantages about knowing real world outcomes and how they diverge from relatively brief randomized controlled trials that do not choose real world patients and are biased at times to the point of being irrelevant by drop outs over time. Additional considerations in terms of the goals of this post include experienced psychiatrists themselves are the typically the best critics of the field. Critics who maintain a specific obvious viewpoint will generally continue to repeat the same criticisms they have been repeating for decades and cannot be considered reliable.  All psychiatrists have varying experiences clinically, in research, and in the literature of the field. An extensive review of psychiatric outcomes over time would seem to be indicated – but there is a lot of applicable research out there right now.  In terms of generating more thorough success rates several biases described above need to be overcome including viewing the necessary data as proprietary or the disingenuous application HIPPA regulations that seem to allow mass marketing of patient data but not allow adequate population-wide quality measures.  I would go as far as establishing a nationwide pharmacosurveillance/pharmacovigilance system to get adequate real world pharmacology data. 

In ending this note I will say that the editorial generated predictable rhetoric.  I typically find myself responding to rhetoric on this blog – but in this case another blogger stepped in and did the heavy lifting.  For anyone interested in the rhetorical side I refer you to the commentary by Awais Aftab, MD who provides excellent responses. Psychiatrists are trained in critiquing their own literature and provide the best legitimate criticism.  A lot of critics outside the field basically repeat what they have been saying for decades.  Those responses tend to be impervious to criticism reflect a general lack of knowledge about the field.  The original editorial by Freedland and Zorumski has merit. It was not intended as a blanket condemnation of the field.  I hope to have fleshed it out a bit in this post and suggested both sources of current data and next steps.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  I am very interested in a large review of psychiatric outcomes.  If you have similar interests and expertise – send me your favorite references or suggestions on how we can collaborate.

 

References:

1:  Freedland KE, Zorumski CF. Success Rates in Psychiatry. JAMA Psychiatry. 2023 Mar 22. doi: 10.1001/jamapsychiatry.2023.0056. Epub ahead of print. PMID: 36947055.

2:  Taipale H, Tanskanen A, Mehtälä J, Vattulainen P, Correll CU, Tiihonen J. 20-year follow-up study of physical morbidity and mortality in relationship to antipsychotic treatment in a nationwide cohort of 62,250 patients with schizophrenia (FIN20). World Psychiatry. 2020 Feb;19(1):61-68. doi: 10.1002/wps.20699. PMID: 31922669; PMCID: PMC6953552.

“These data suggest that long-term antipsychotic use does not increase severe physical morbidity leading to hospitalization, and is associated with substantially decreased mortality, especially among patients treated with clozapine.”

3:  Tiihonen J, Tanskanen A, Taipale H. 20-Year Nationwide Follow-Up Study on Discontinuation of Antipsychotic Treatment in First-Episode Schizophrenia. Am J Psychiatry. 2018 Aug 1;175(8):765-773. doi: 10.1176/appi.ajp.2018.17091001. Epub 2018 Apr 6. PMID: 29621900.

“Whatever the underlying mechanisms, these results provide evidence that, contrary to general belief, the risk of treatment failure or relapse after discontinuation of antipsychotic use does not decrease as a function of time during the first 8 years of illness, and that long-term antipsychotic treatment is associated with increased survival.”

4:  Tiihonen J, Wahlbeck K, Lönnqvist J, Klaukka T, Ioannidis JP, Volavka J, Haukka J. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study. BMJ. 2006 Jul 29;333(7561):224. doi: 10.1136/bmj.38881.382755.2F. Epub 2006 Jul 6. PMID: 16825203; PMCID: PMC1523484.

16 yr study

“The effectiveness of first and second generation antipsychotics varies greatly in the community. Patients treated with perphenazine depot, clozapine, or olanzapine have a substantially lower risk of rehospitalisation or discontinuation (for any reason) of their initial treatment than do patients treated with haloperidol. Excess mortality is seen mostly in patients not using antipsychotic drugs.”

5:  Taipale H, Lähteenvuo M, Tanskanen A, Mittendorfer-Rutz E, Tiihonen J. Comparative Effectiveness of Antipsychotics for Risk of Attempted or Completed Suicide Among Persons With Schizophrenia. Schizophr Bull. 2021 Jan 23;47(1):23-30. doi: 10.1093/schbul/sbaa111. PMID: 33428766; PMCID: PMC7824993.

6:  Tiihonen J, Mittendorfer-Rutz E, Majak M, Mehtälä J, Hoti F, Jedenius E, Enkusson D, Leval A, Sermon J, Tanskanen A, Taipale H. Real-World Effectiveness of Antipsychotic Treatments in a Nationwide Cohort of 29 823 Patients With Schizophrenia. JAMA Psychiatry. 2017 Jul 1;74(7):686-693. doi: 10.1001/jamapsychiatry.2017.1322. PMID: 28593216; PMCID: PMC5710250.

7:  Heikkinen M, Taipale H, Tanskanen A, Mittendorfer-Rutz E, Lähteenvuo M, Tiihonen J. Real-world effectiveness of pharmacological treatments of alcohol use disorders in a Swedish nation-wide cohort of 125 556 patients. Addiction. 2021 Aug;116(8):1990-1998. doi: 10.1111/add.15384. Epub 2021 Jan 14. PMID: 33394527; PMCID: PMC8359433.

8:  Lähteenvuo M, Tanskanen A, Taipale H, Hoti F, Vattulainen P, Vieta E, Tiihonen J. Real-world Effectiveness of Pharmacologic Treatments for the Prevention of Rehospitalization in a Finnish Nationwide Cohort of Patients With Bipolar Disorder. JAMA Psychiatry. 2018 Apr 1;75(4):347-355. doi: 10.1001/jamapsychiatry.2017.4711. Erratum in: JAMA Psychiatry. 2022 May 1;79(5):516. PMID: 29490359; PMCID: PMC5875349.

9:  Puranen A, Koponen M, Lähteenvuo M, Tanskanen A, Tiihonen J, Taipale H. Real-world effectiveness of mood stabilizer use in schizophrenia. Acta Psychiatr Scand. 2023 Mar;147(3):257-266. doi: 10.1111/acps.13498. Epub 2022 Sep 14. PMID: 36065482.

10:  Tiihonen J, Haukka J, Taylor M, Haddad PM, Patel MX, Korhonen P. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry. 2011 Jun;168(6):603-9. doi: 10.1176/appi.ajp.2011.10081224. Epub 2011 Mar 1. Erratum in: Am J Psychiatry. 2012 Feb;169(2):223. PMID: 21362741.

11:  Tiihonen J, Tanskanen A, Hoti F, Vattulainen P, Taipale H, Mehtälä J, Lähteenvuo M. Pharmacological treatments and risk of readmission to hospital for unipolar depression in Finland: a nationwide cohort study. Lancet Psychiatry. 2017 Jul;4(7):547-553. doi: 10.1016/S2215-0366(17)30134-7. Epub 2017 Jun 1. PMID: 28578901.

12:  Tiihonen J, Lönnqvist J, Wahlbeck K, Klaukka T, Tanskanen A, Haukka J. Antidepressants and the risk of suicide, attempted suicide, and overall mortality in a nationwide cohort. Arch Gen Psychiatry. 2006 Dec;63(12):1358-67. doi: 10.1001/archpsyc.63.12.1358. PMID: 17146010.

13:  Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E. Reducing all-cause mortality among patients with psychiatric disorders: a population-based study. CMAJ. 2013 Jan 8;185(1):E50-6. doi: 10.1503/cmaj.121077. Epub 2012 Nov 12. PMID: 23148054; PMCID: PMC3537812.

14: McMahon FJ. Prediction of treatment outcomes in psychiatry--where do we stand ? Dialogues Clin Neurosci. 2014 Dec;16(4):455-64. doi: 10.31887/DCNS.2014.16.4/fmcmahon. PMID: 25733951; PMCID: PMC4336916.

15: Bell, L., 1849. On a form of disease resembling some advanced stageof mania and fever. Am. J. Insanity 6, 97–127. 

16:  Taipale H, Schneider-Thoma J, Pinzón-Espinosa J, Radua J, Efthimiou O, Vinkers CH, Mittendorfer-Rutz E, Cardoner N, Pintor L, Tanskanen A, Tomlinson A, Fusar-Poli P, Cipriani A, Vieta E, Leucht S, Tiihonen J, Luykx JJ. Representation and Outcomes of Individuals With Schizophrenia Seen in Everyday Practice Who Are Ineligible for Randomized Clinical Trials. JAMA Psychiatry. 2022 Mar 1;79(3):210-218. doi: 10.1001/jamapsychiatry.2021.3990. PMID: 35080618; PMCID: PMC8792792.

17: Taipale, H. and Tiihonen, J. (2021) “Registry-Based Studies: What They Can Tell Us, and What They Cannot,” European Neuropsychopharmacology, 45, pp. 35–37. doi: 10.1016/j.euroneuro.2021.03.005. 

18:  Lähteenvuo M, Paljärvi T, Tanskanen A, Taipale H, Tiihonen J. Real-world effectiveness of pharmacological treatments for bipolar disorder: register-based national cohort study. Br J Psychiatry. 2023 Oct;223(4):456-464. doi: 10.1192/bjp.2023.75. PMID: 37395140.

One More Dream…..

 

One More Dream…

The purpose of this post is an illustration of a strategy I use to improve my sleep.  I am currently an old man and have had sleep problems since I was a toddler. I had night terrors at an early age and still remember the hallucinations.  I wrote about them in a previous post.  Night terrors as a kid generally predicts sleep problems and risk for psychiatric difficulty as an adult. I also inherited obstructive sleep apnea and that contributes to poor sleep quality. For most of my career, I practiced in a high stress environment and with my personality factors that also lead to significant sleep disruption in situations where there was no clear solution to the problems I was trying to treat. A good example would be catatonic patients who were not eating, drinking, or responding to treatment. I would find myself laying in bed at night and reviewing the current treatment plan and that person’s medical status – sometimes for hours. Since retiring 2 years ago that type of nocturnal stress is gone – but your life is never completely stress free.

When I do fall asleep – I generally like dreaming. I tend to dream about medical centers and anxiety provoking situations. A common dream is being in residency and realizing that I just stopped going to biochemistry class as a first-year medical student. I never took the exams or confirmed whether I got a grade or not. Instead, I find myself near the end of residency and wondering if I am going to graduate.  I am not sure if there is a black mark against my name or not. At the same time, I am engaged with many doctors – doing what we did in residency training. I wake up somewhat anxious until I realize it is just a repetitive dream. I am always amazed at the content of the dream in terms of the architecture and landscape – all manufactured from incidental memory. None of the institutions in my dreams exist in real life. The same is true of most of the people in my dreams, but occasionally there is a friend, family member, or celebrity.

I try to practice the lucid dreaming that I discovered in childhood. If I am stressed or anxious in a dream, especially to the point of bodily sensations like feeling flushed, like my heart is pounding, or shortness of breath I try to wake myself up by rehearsing what to do ahead of time.  Those bodily sensations can be associated with strenuous activity in the dream like skating or biking – but not always.  I have tried a lot of the relaxation and CBT techniques for falling asleep but did not find them very effective. I also have not used any medications for sleep.  My primary care MD gave me 3 zolpidem tablets once.  They were moderately effective but he did not prescribe any more.  I take medication that is toxic and has drug interactions so I did not try other options that might affect cardiac conduction.

What I did come up with was a technique that I call “One more dream.”  Before I get into the details – let me emphasize that this is not an instruction manual or guide for people to use this technique.  It has not been shown to be effective in clinical trials and doubt it will ever be studied. This is just a technique that I personally have found to be effective and it is not medical advice for anyone else.  And like everything on this blog I am not promoting it to make money.  The discussion is strictly educational – nothing more.

Here is an outline of the basics beyond the typical sleep hygiene measures:

1: Recall the somatic sensations just before you fall asleep:  These sensations vary widely from person to person.  In my case, I get a feeling that I am sinking and I start to lose sensation in my arms and hands – they start to feel very light. I am also aware of any stiffness in the chest and abdominal wall.  I will typically do a few breathing exercises to get rid of that stiffness.  I actively try to recall that sequence of events and the actual feeling.  I have had several instances of general anesthesia in the past 5 years and recalling that state can also be helpful. 

2:  Recreate 'sleep reverie' transition state (usually just waiting for it is enough):  Sleep reverie is the transitional state from wakefulness to sleep. There is typically a period where conscious thoughts start to run together.  If you are good at mental imagery – an image might start out with a person walking down a stairway and change in an instant to a different person engaged in a different activity.  Noticing when this occurs is typically associated with transitional images. It is also a sign that sleep is rapidly approaching.  Focusing on those instances is helpful. 

3:  The conscious goal is one more dream:  I typically try to focus on an image of something that I want to dream about but having that dream is extremely rare. These images often dissolve in the sleep reverie stage. It is also a time to rehearse endings to problematic dreams. A common theme for me is strenuous physical activity. I am overexerting myself in a dream and wake up to rapid heartbeat, palpitations, rapid breathing, and sweating. If I can recognize that in a dream – my usual rehearsed ending is to wake up and start over.   

Those are the basic steps and the mile high view. They are not completely original since there are elements of lucid dreaming and dream/imagery rehearsal – both of which have been studied, tested and used clinically (1). In clinical practice I have had good results advising people about sleep hygiene; the pharmacology of caffeine, alcohol, and addictive drugs; whether their dreams were interpretable; and how to stop unpleasant dreams or nightmares using dream rehearsal. The decision to use these techniques generally depends on the amount of autonomic arousal the person is experiencing.  For example, people with high levels of anxiety all day long who experience associated nightmares and nocturnal arousal including panic attacks, rapid heartbeat, palpitations, sweating, and ongoing sleep deprivation are much more likely to need pharmacotherapy in addition to the above measures.  Standard insomnia therapies may be useful, but more specific therapy targeting heightened adrenergic output is more likely to work, especially in the case of post traumatic nightmares.

The biology of sleep transitions remains at the theoretical stage at this point with several interesting classical and newer hypotheses (2,3).  While the hypotheses are interesting and becoming more sophisticated it is also apparent that pluralistic interventions are effective including the measures described in this post.  In other words, astute clinicians have been able to design self-help, structured, and psychotherapeutic interventions that can reduce or eliminate both primary and trauma-based nightmares and improve sleep quality and general health.  Like many other interventions in psychiatry - they work irrespective of whether a biological mechanism of action is known or not. They also do not depend on a prescribed medication or medical test. They are dependent on a skilled sleep assessment and training in these techniques.

 

George Dawson, MD, DFAPA

 

References:

1:  Yücel, D. E., van Emmerik, A. A. P., Souama, C., & Lancee, J. (2020). Comparative efficacy of imagery rehearsal therapy and prazosin in the treatment of trauma-related nightmares in adults: A meta-analysis of randomized controlled trials. Sleep Medicine Reviews, 50, https://doi.org/10.1016/j.smrv.2019.101248

2:  Saper CB, Fuller PM, Pedersen NP, Lu J, Scammell TE. Sleep state switching. Neuron. 2010 Dec 22;68(6):1023-42. doi: 10.1016/j.neuron.2010.11.032. PMID: 21172606; PMCID: PMC3026325.

3:  Osorio-Forero A, Cardis R, Vantomme G, Guillaume-Gentil A, Katsioudi G, Devenoges C, Fernandez LMJ, Lüthi A. Noradrenergic circuit control of non-REM sleep substates. Curr Biol. 2021 Nov 22;31(22):5009-5023.e7. doi: 10.1016/j.cub.2021.09.041. Epub 2021 Oct 13. PMID: 34648731.

 

Likely and Unlikely Causes of Mass Shootings

     

The pace of mass shootings and school shootings in the United States continues unabated at this time. I am writing this like I have written many posts in the past – a few days after a mass shooting in a school.  I just heard a news reports saying that this was the 167^th school shooting since Columbine on April 20, 1999.  NPR posted a story saying that there is a shooting or a potential for shooting in schools every day (1) – based either on a gun discharge of someone brandishing a firearm in school. They reference the K-12 School Shooting Database stating that this is the 39^th incident this year that involved gunfire on school grounds.

The media descriptions of the current incident follow much of the coverage in the past about unclear motive, shocking circumstances, unpredictability, questions of an “emotional disorder” and counseling, and the devastating impact on families and the community. I saw a forensic psychiatrist interviewed speculating on the aggressive dynamics based on the detail that the shooter recently disclosed a transsexual orientation.  A clergyman was interviewed and suggested the shooter was really looking for the school minister who was providing counseling.  One of the shooter’s fiends was interviewed.  She was contacted immediately prior to the incident and promptly notified authorities – but by then it was too late. The video of the SWAT team running through the hallways and eventually running toward gunfire and killing the shooter keeps playing.  In some cases that video is compared directly to the Uvalde, Texas video  and comments are made about this is a much better example of how law enforcement should respond. I saw some of these reports where they put up the response time on the screen.  

There are the usual expressions of “enough is enough” and “we don’t send our kids to school for this to happen.”  Republican Representative Tim Burchett came right out and said what most people were thinking: “ We’re not gonna fix it….” But then to make it more palatable he added: “criminals are gonna be criminals.”  He thought we needed a “revival” to “change peoples’ hearts in this country.” Later he disclosed he was home schooling his daughter (3).

I am already on record on this blog writing about the real cause of mass shootings and gun violence in general and it is the politics of gun extremism.  The Republican party has figured out that gun extremism works for them along with several other easily demagogued social issues like abortion, voter suppression, education, anti-science, anti-climate change, and more recently “wokeism”. That has led to a series of initiatives to drastically reduce gun regulations.  There has been an undeniable increase in deaths due to gun violence.  Mass shootings, suicide, homicide, and accidental deaths are all routinely ignored as calls for regulations that were effective for decades until Republican advocates rolled them back – even though gun regulations in the past were never a problem.

The typical rhetoric used is a gun extremist interpretation of the Second Amendment.  In the case of voters, it was the usual emotional appeal that “they” were coming to take their guns.  Anyone familiar with the distribution of guns in the United states realizes this is an impossibility, but it is a rallying point for emotional rather than rational appeals.  In recent years we have seen the rhetoric extended to mental illness as a cause of mass shootings.  There is some confluence with antipsychiatry factions who falsely equate psychiatry with the pharmaceutical industry and suggest that antidepressant drugs cause the mass shooting phenomena.  This post will provide clear evidence to the contrary.

On the issue of common psychiatric disorders in comparing the countries that utilize the most antidepressant prescriptions – the prevalence of those disorders is consistent among the United States and the other countries at the top of the list.  These disorders include depression, anxiety disorders, and substance use disorders – conditions that antidepressants are all commonly prescribed for. English speaking and European countries had similar prevalence (4) with possibly lower prevalence in Asia. There are similar variations in the estimated prevalence of schizophrenia and mood disorders in different areas of the world (5, 6).  

A good summary document on the research about mental illness and mass shooting incidents is available from the Treatment Advocacy Center (10).  They summarize the results of several studies as indicating that at least one third of the perpetrators had "serious untreated mental illness."  Their review is remarkable for a wide range of methodologies and selection biases that probably overestimates the number of cases of severe mental illness in mass shootings.  Smaller sample sizes generally showed a greater number of cases of severe mental illness.  In the case of a study by Stone (11) he found that 32% of 228 mass killers had severe mental illness but during the sampling period there were 1,000 incidents.  The variation is often considered due to methodological differences in the surveys but as previously illustrated– even significant differences in incidence and prevalence of these disorders is unlikely to account for the huge differences in gun deaths between the USA and other countries.  The main difference is that people with the same mental illnesses have much easier gun access in the US.

Several studies of people involved as shooters have shown that some of them have psychiatric diagnoses and in some cases they are being treated by psychiatrists.  Some are prescribed medications but the toxicology at the time of the incident is typically not available. In a related study of murder-suicide by the New York City Medical Examiner’s office that of 127 cases over a 9-year period only 3 (2.4%) were taking antidepressants (7).  Two were taking amitriptyline and 1 was taking sertraline. The authors made the point that antidepressant use in this case series was much lower than the expected population rate.  In a series of 27 elderly men who killed their spouse and then died by suicide – more disease conditions and depression were seen as possible predisposing factors – but none tested positive for antidepressants (8).  When considering the prescribing of antidepressants in general,  epidemiological studies suggest that most of these medications are prescribed by non-psychiatrists. With the proliferation of non-physician prescribers, managed care strategies designed to accelerate antidepressant prescribing based on limited assessments, and widely advertised televisit prescribing it is likely that gap between psychiatrist and other prescribers has increased substantially and will continue to grow.

The argument has been made that people become agitated, suicidal, and homicidal on antidepressants. This is a recurrent theme that is often related to medicolegal considerations, criticism of the pharmaceutical industry, and psychiatric criticism.  There is often a suggested scenario of the antidepressants (especially selective serotonin reuptake inhibitors or SSRIs) causing agitation or activation making suicidal or aggressive behavior more likely.  After reviewing the existing evidence the FDA has placed a black box warning for suicidality in "children, adolescents, and young adults".  There are also warning and counseling bullet points on clinical worsening as evidence by: "emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down".  Standard medical and psychiatric practice advises the patient of these potential risks and what the plan should be if they occur.  In 35 years of clinical practice my observations were that these symptoms were rare and most likely to occur if an antidepressant was discontinued and the patient experienced significant sleep disturbance. The patients I treated with severe aggressive behavior were generally untreated for psychiatric disorders and often had substance use disorders.  A recommendation I have not seen is that all of these incidents should be studied from a prospective comprehensive psychiatric standpoint as they occur with no selection bias.  That study should include toxicology, detailed collateral information, analysis of available medical records, and post mortem analysis if relevant.

In choosing a reference (9) for international comparison of mass shooting phenomenon it is important to consider how the database is constructed. In choosing reference 9, the author described a clear rationale and methodology.  The basic criteria include an incident where there are at least 4 shooting deaths and the shooter is acting alone and not due to criminal or terroristic motivations. Since mass shootings in the US have been motivated by neither – there would be no equivalent comparison with incidents in the US. The author also compares the US to the 35 United Nations definition economically developed countries (see Supplement 1). The time frame of 1998-2019 was chosen.  On that basis half of the countries did not have a single mass shooting incident, ten had more than one, five had more than 20 fatalities, and the US had 12 times as many incidents as the country with the second most mass shootings. Much greater detail is included in the original reference.

I prepared two reference tables based on this data (click on either table for a better view).  The graphic at the top of this page does not include suicide and homicide rates for each country.  The table below includes both of these rates.  Data sources are referenced in the tables.  

 

The countries are arranged by defined daily doses (DDD) of antidepressant medications.  DDD is a World Health Organization (WHO) defined metric for medication utilization. It looks at the total amount of a defined class of medication using the Anatomic Therapeutic Chemical (ATC) classification based on the usual prescribed dose of medication. In that system antidepressants are listed as a class.  US data are highlighted in the table because they represent the focus of this post.

What are some likely and unlikely observations from the Table.  First, it is unlikely that antidepressant prescriptions are a proximate cause of mass shootings.  The countries bracketing the US in antidepressant utilization (Iceland and Portugal) each had no mass shooting during the period of interest (1999-2018).  Second, gun availability stands out as an obvious factor in mass shootings, gun related suicides, and gun related homicides.  Third, gun availability in the US (120.5 firearms per 100 person) nearly equals gun availability in every other country in the table (128.4 firearms per 100 persons).  Fourth, no country had homicide rates similar to the US, but 3 of the countries had similar suicide rates but much lower rates of gun suicides. The reference study looks at locations, relationships, and firearms as relevant points but no comments on mental illness or toxicology at the time of the incident. The author also points out that in many countries mass shootings trigger government intervention focused on decreasing the likelihood of future shootings.  Except for a time limited assault rifle ban that does not happen in the United States.  The gun regulatory landscape is headed in the opposite direction with a movement to permitless access to handguns.

In summary, the gun violence landscape in the United States is bleak. Despite rationalizations that this is really a mental illness or mental illness treatment problem there is no real supporting evidence, since the distribution of mental illnesses in the US is the same as comparable countries with no to few mass shootings. There is low quality evidence that mental illness may be a factor in 15-30% of incidents - but the only way to explain why that is a factor is those people have much easier access to firearms.  The overwhelming evidence is that this is a problem of gun extremism, gun access, and sociocultural factors like subcultural acceptable violence, media notoriety, and politically reinforced messaging about gun use. The only way to address the problem based on international examples is to decrease gun access.  That is unlikely as long as one major party and their appointed judges need to activate their base with false messaging and flood the country with easy to access firearms.  They bear the ultimate responsibility.

George Dawson, MD, DFAPA

 

Supplementary 1:  UN Classified Developed Countries (total of 36) for reference 3 in Table and reference 9 below:  Australia, Austria, Belgium, Bulgaria, Canada, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Latvia, Lithuania, Luxembourg, Malta, Netherlands, New Zealand, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom, and the United States.

 

 References:

1:   Florido A, Summers J. By one measure, the U.S. has had a shooting on school grounds almost every day.  https://www.npr.org/2023/03/28/1166630346/by-one-measure-the-u-s-has-had-a-shooting-on-school-grounds-almost-every-day

2:  K-12 School Shooting Database:  https://k12ssdb.org/all-shootings

3:  Winter J.  After the Nashville shooting a faithless remedy for gun violence. New Yorker.  Amrch 29, 2023:  https://www.newyorker.com/news/daily-comment/after-the-nashville-school-shooting-a-faithless-remedy-for-gun-violence

4:  Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980-2013. Int J Epidemiol. 2014 Apr;43(2):476-93. doi: 10.1093/ije/dyu038. Epub 2014 Mar 19. PMID: 24648481; PMCID: PMC3997379.

5:  Goldner EM, Hsu L, Waraich P, Somers JM. Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature. Can J Psychiatry. 2002 Nov;47(9):833-43. doi: 10.1177/070674370204700904. PMID: 12500753.

6:  Waraich P, Goldner EM, Somers JM, Hsu L. Prevalence and incidence studies of mood disorders: a systematic review of the literature. Can J Psychiatry. 2004 Feb;49(2):124-38. doi: 10.1177/070674370404900208. PMID: 15065747.

7:  Tardiff K, Marzuk PM, Leon AC. Role of antidepressants in murder and suicide. Am J Psychiatry. 2002 Jul;159(7):1248-9. doi: 10.1176/appi.ajp.159.7.1248. PMID: 12091219.

8:  Malphurs JE, Eisdorfer C, Cohen D. A comparison of antecedents of homicide-suicide and suicide in older married men. Am J Geriatr Psychiatry. 2001 Winter;9(1):49-57. PMID: 11156752.

9:  Silva JR. Global mass shootings: Comparing the United States against developed and developing countries. International Journal of Comparative and Applied Criminal Justice. 2022 Mar 21:1-24.

10: Treatment Advocacy Center.  Serious Mental Illness and Mass Homicide. June 2018,  https://www.treatmentadvocacycenter.org/key-issues/violence/3626-serious-mental-illness-and-mass-homicide

11:  Stone, M. F. (2015). Mass murder, mental illness, and men. Violence and Gender. 2015; 2, 51-86.