Riffing off A Powerful Message

A week’s worth of (medicated) sleep, and my noggin can at least process a few thoughts, here and there. 1 boring old man published an important post titled, A Powerful Message.  He chronicled the increasing clamor of psychiatry to use a neural circuitry model as evidence of psychopathologic causality and therefore an avenue for research and treatment.  I had noticed this, too, with increasing alarm and a sense of deja vu. I yammered a bit in a comment:

As a long time critical care nurse and educator, I witnessed an enormous transition in thinking about the care and treatment of myocardial infarctions (heart attacks). Care and treatment initially and historically was focused on complete bed rest and inactivity – up to and including only allowing room temperature food and drink lest cold irritate the vagus nerve. As the plumbing and electrical circuitry interface with the muscle stimulation and perfusion became more well known, treatments became more aggressive – getting patients up and moving right away, reperfusing coronary arteries and stenting them, ablating lesions, etc. Then the focus spotlighted statin use for prevention, concomitant with pharma DTC advertising and KOLs. Only recently has any of this been questioned, and lo and behold, stenting and preventive statin use may not do anything at all in terms of disease prevention.

Not for nuthin’ has clinical depression been found to coexist and correlate with heightened morbidity and mortality with of heart disease.

Patient stays in critical care units for heart attacks (MIs) went from 7-10 days to 1-2. Of course, patient education, diet teaching, stress management, socioeconomic assessment went out the window. In other words, self management and quality of life factors were ignored and abandoned. Patients are sent home with prescriptions, stents, pacemakers, automatic internal defibrillators and all manner of coronary hardware, and sometimes followup appointments. They are not linked to case managers, community resources and psychosocial supports.

The forces of capitalism, free markets and decreasing corporate regulation have converged to erode worker protections, environmental protections, food safety, community development (corporations receiving tax breaks, outsourcing jobs to other countries and pulling up stakes, leaving communities dying on the vine), and overall, contributing to the deterioration of social life and community throughout the US.  Vicious and poisonous politics have contaminated the well of civil discourse.

Whither health and well-being?

Here, my collegiate roots show.  Case Western Reserve University’s Frances Payne Bolton School of Nursing and the Department of Nursing Education, Teachers College, Columbia University, both were founded on the critically important work of nurses who established, grew, and nurtured public health and psychiatric nursing theory and practice.  My education was based on the principles and practices of Lillian Wald, Hildegard Peplau, Virginia Henderson, Isabel Hampton Robb (yes, the Robbs of Johns Hopkins and later, Lakeside Hospital of Case Western Reserve – this hospital was noted by Flexner in his famous Report on Medical Education, for serving as an exemplar), and Mary Adams, pioneer in gerontologic nursing and later a Dean at her home state, South Dakota’s State University School of Nursing.  These names will mean nothing to almost all members of the public, physicians, and sorry to say, nurses.

But I hope you’ll click on the links because their work has critical importance and influence on the individual, family and community health and well-being of Americans today. What you will see is their universal concern with the immediate and larger social and community environments which affect health and well-being of the targeted patient populations.

Physicians, nurses and indeed, all members of the (licensed, ergo, regulated) helping professions have an obligation to address, influence and lead policy and programming which are congruent with and supportive of a healthy environment and social life.  Those include wages which allow adults to work a single job and provide for safe shelter, clean water and air, nutritious fresh whole foods, reliable transportation, access to education and natural recreational facilities and adequate protective clothing for themselves and dependents.  It means assuring clean air and potable water.  It means assuring access for all to basic communicable disease prevention: vaccines, safe food, zoonoses prevention.  It means worker protections which promote tolerable physical and psychological stress levels.  It means protections for whistleblowers – rewarding workers for upholding ethical business, research and professional ethics.  It means promoting civil discourse and discouraging ostracism – whether that be racism, bullying, intimidation or any other type of behavior which is exclusionary.

Embracing the classical virtues and publicly upholding the inherent worth of every person will lead more to health and well-being than any pill, potion, invasive treatment or state of the art assessment tool.

The bottom line:  Each and every member of a helping profession by the social contract is an agent for social change.  Without that, patient treatment is devoid of care. And treatment will only palliate and blunt symptoms, rather than address disease and distress causality. Futile, impotent and, ultimately, destructive. Like this, perhaps:

Chasing Tails

Thomas Joiner’s interpersonal theory of suicide is one I refer to often here.  However, even he doesn’t move upstream to look at distress causality.  Exhibit the last:

J Psychiatr Res. 2012 Apr 2. [Epub ahead of print]

Behaviorally-indexed distress tolerance and suicidality.

Source

Military Suicide Research Consortium, United States.

Abstract

Research indicates that distress tolerance exhibits a complicated relationship with risk factors for suicidal behavior. Specifically, low self-reported distress tolerance has been linked to perceived burdensomeness and thwarted belongingness. Contrastingly, high self-reported distress tolerance has been linked to the acquired capability for suicide. Given the frequently discrepant findings between self-report and behavioral indices of distress tolerance, we sought to expand upon prior findings by testing these relationships utilizing a behavioral measure of distress tolerance. Additionally, in an effort to further clarify the role of distress tolerance relative to painful and/or provocative experiences in the acquired capability, we examined whether distress tolerance serves as a moderator. Results revealed no significant associations between distress tolerance and burdensomeness or belongingness; however, distress tolerance was positively associated with the acquired capability. Furthermore, the interaction of distress tolerance and painful and/or provocative experiences significantly predicted the acquired capability, with the strength of the association increasing at higher levels of distress tolerance. Results highlight the potential importance of perceived versus actual ability to tolerate distress with respect to suicidal desire. In contrast, the results reflect the importance of actual persistence in the acquired capability.

TNTC

TNTC in the healthcare trade refers to too numerous to count, often referring to types of cells on a slide.

I’ve been reading all sorts of studies and reports and have managed to keep TNTC tabs open.  I’m not able to concentrate well enough to put them into much of an interesting and pertinent context, so here they are, more or less in list form.  Perhaps another day the noggin will be more willing to oblige in the coherence and cogitation departments….

Kaiser Health News (an excellent resource) reports on states cutting mental health budgets concurrent with need and use increases.

Despite the sketchy, COI (conflict of interest) riddled authors, this is an interesting review.

This review summarizes the phenomenon of adult hippocampal neurogenesis, the initial and continued evidence leading to the development of the neurogenesis hypothesis of depression, and the recent studies that have disputed and/or qualified those findings, to conclude that it can be affected by stress and antidepressants under certain conditions, but that these effects do not appear in all cases of psychological stress, depression, and antidepressant treatment.

This study refers to people who committed suicide as “depressed suicides”.  Ahem, authors, suicide is a verb and not a noun to be used to pathologize a person as an act. I included it because it found credible evidence of neuroinflammation in people who were diagnosed prior to their deaths with severe depression. (I’ve been eating an anti-inflammatory diet which has provided some health benefits, but to date, has not mitigated depression or PTSD.  However, my labs are golden.  Whoopee.)

These results provide the first evidence of altered cortical astrocytic morphology in mood disorders. The presence of hypertrophic astrocytes in BA24 white matter is consistent with reports suggesting white matter alterations in depression, and provides further support to the neuroinflammatory theory of depression.

Shotgun ’em. This study looked at the outcomes of people who were prescribed antipsychotic medications for anxiety. Except for the adverse effects, not much good happened. Lesson: don’t let this happen to you.

Lithium has a reputation for lowering the suicide rate. When it was stacked up next to valproate, not so much.

Despite the high frequency of suicide events during the study, this randomized controlled trial detected no difference between lithium and valproate in time to suicide attempt or suicide event in a sample of suicide attempters with bipolar disorder.

Australian national youth suicide prevention strategy didn’t affect the suicide rate – just like every other prevention strategy globally.

Yet another suicide rating scale – this time it’s the Columbia-Suicide Severity Rating Scale C-SSRS. It’s apparently reliable for suicidality but not for actual attempts. Kindling effect, people. Keep asking questions which demand extensive detailed thought about planning, the method, the needed resources and the desire, and hey – look at this bright shiny object – the biggest risk factor for suicide is prior attempts. Practice and rehearsal (mental as well as physical) makes perfect. Still conflating assessment with treatment with iatrogenically lethal result.

I’m stopping here, although there are many, many more links to go.

Predictions

Honestly.  In the conflation department, I keep reading comments about how much a need there is to have a reliable tool to predict suicides.  Well, that ain’t happenin’ until there is effective, available and safe treatment which reduces distressors.  Otherwise, all of the rewards and incentives are lined up squarely against anyone admitting suicidality, let alone seeking incarceration quaintly and deceptively referred to as containment and hospitalization, applied emotional trauma, humiliation and intrusiveness which is all the “standard of care” does in the US, at least, when someone admits to suicidality.

I have been explicitly instructed by three psychiatrists on how to dodge a suicidality assessment in order for us to play charades:  me, so that I escape imprisonment and them to escape legal risk and actually intervening to alleviate my distress.  So why in the world would I seek out any “help” at all when it is clear that there is none to be had?  Sheer lunacy, (irony alert).

And so, the world goes on without me. Silence punctuated by external noise. Unending hell. No reason to get up, go anywhere, do anything. There is no intervention for ostracism.  Untouchable, literally untouchable. Enduring social death until physical death.  Hurry up, already.

For those who have friends and family, a recent large scale study examined some of the factors involved in them not intervening or providing help when people close to them are suicidal:

As the suicidal process unfolds, significant others are required to make a series of complex decisions about what is happening and what, if anything, they should do about it. They must collect and weigh evidence from a range of sources, correctly decipher and assess the significance of both signs and countersigns, identify the appropriate actions to take, and then summon the courage to take them. Risks are involved at every stage; cherished relationships are at stake. Significant others must weigh the danger of doing nothing against the perceived dangers of saying or doing “the wrong thing.”

Experts agree that a clear and unambiguous warning message is a prerequisite for effective disaster planning and crisis management.29 Our data suggest that, in a suicidal crisis, members of the family and social network may not always receive a clear and unambiguous warning message. This may be because the person fails to give out a clear enough distress signal or because distress signals are given but significant others cannot decode them correctly at the time  Equally, they may not be able to bring themselves to accept that anything is seriously wrong or that suicide is a possibility. Writing in another context, about clinical identification of child abuse, one author comments: “[It] is a difficult intellectual and emotional exercise. . . The biggest barrier to diagnosis is the existence of emotional blocks in the minds of professionals.”30 The emotional blocks that can operate in clinical practice are magnified many times in close personal relationships, where every word or action may be emotionally charged and gauging the right response is critical. Our findings suggest that those very relationships, generally believed to be a protective factor for suicide,31 32 may sometimes heighten risk by acting as barriers to both awareness and intervention.

….critical errors in judgment often result from the so-called “normalcy bias,” defined as the tendency of people who have never experienced a catastrophe to disregard ominous signs and behave as if nothing is wrong. The strong desire for everything to be normal inclines people to believe that it is, even in the face of evidence to the contrary.33 Our findings suggest that this same principle may operate at the private level, particularly in the context of family life. The cycles of avoidance model, proposed by Biddle et al to account for non-help seeking for mental distress, provides an alternative framework that also fits our data well.   Our data show that lay people may go to considerable lengths to avoid pathologising the distress of those close to them; their thresholds are repeatedly pushed back by powerful emotions, especially fear of the consequences (for themselves, as well as for the distressed person) of acknowledgment and intervention.

What Protects?

I’m working a bit sideways and backwards since I haven’t developed a more comprehensive explanation of suicidality prompts.  But there have been several studies in the news which address compensatory mechanisms and adaptation, so the time’s right to get them out there for people to consider.

To experience external physical warmth which approximates human or possibly mammalian warmth is a basic human need. It turns out that when lonely college students were queried on bathing behaviors, those reporting higher degrees of loneliness had significantly different habits.  They bathed/showered more frequently, for longer periods of time and they used warmer water temperatures.  The authors postulate that this is a self-soothing strategy which serves as a rough proxy for human warmth.

The Ohio State University published a study demonstrating an association between particulate pollution and clinical depression.  Given the inflammatory involvement in depression, these finding serve as more fuel for this fire.  It might be worth trying room-based air filters to see if people get any anti-inflammatory effects. More research needs to be done in essential quality of life factors.

The website, Ostracism Aware, has a resource listing which seems to be fairly comprehensive.

What do you find helps to relieve the feelings of isolation, loneliness, not belonging, depression or being a burden? What doesn’t help?  What do other people do that helps?  And what do other people do that makes things worse?

Suicide

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Suicide remains an unmentionable in the US.  People who act upon suicidality are forcibly restrained, imprisoned (involuntarily confined), intensely and intrusively observed, and are subjected to treatment and conditions which make the already unbearable even moreso.

I aim to move upstream and address the conditions which lead toward unbearable distress, what Thomas Joiner has termed thwarted belongingness and perceived burdensomeness, and overwhelming despair.

I want to explore what people find helpful, how they are comforted and reassured, and what stops suicidality from developing to the point that the distress is incompatible with life – a phrase that is used in pathophysiology to describe a condition in which a living organism can no longer survive. I also want to go further and discover what prevents suicidality from occurring in the first place.

To that end, this blog is a safe venue in which to discuss the taboos, the precipitants, and all of the hidden and concealed facets around suicidality.  No one will track or monitor visitor identities.  There will not be online interventions responding to statements about intending to end one’s life. Your autonomy over your own life is respected.  To that end, comments that threaten harm as a manipulating device will not be published.

The overarching purpose is to address ways to relieve and to prevent feelings of intolerable distress.  People who would like to author around these topics are welcome and may drop me an email to discuss.