May 29

96 Hour Involuntary Holds Save Lives

By Dr. Micaela Wexler

In the aftermath the murderous rampage at UC Santa Barbara May 2014, I found myself feeling profoundly grateful to be practicing psychiatry in Missouri, a state that allows law enforcement officers to issue a warrant on people suspected of having a mental health crisis so they can be taken to an emergency room to be evaluated by a mental health provider for an involuntary hold for 96 hours. The public has been eager to blame this rampage on an easily identifiable cause. It has been blamed on misogyny, easy access to guns, video games. Our collective ignorance of mental health issues allows us to blame these factors, while allowing mental illness to claim more lives. At the same time, we ignore, or take for granted factors which allow the mental health system to work.

In this part of Missouri, guns are ubiquitous. So are video games. It is popular for young men to express misogynistic views. Given what I have seen in the media, we should be having these sorts of events all the time here in Missouri. The fact we are not may be due to the role of the 96 hour involuntary hold. If a family member or therapist suspects a person may be in crisis, law enforcement officers do a “wellness check.” Very often, the person is taken to the nearest emergency room to be evaluated by a mental health professional who can then determine if the person requires an involuntary 96 hour hold.

In looking at the videos and reading the killer’s manifesto, it is clear to me, as a psychiatrist, that it is very possible he was experiencing a bipolar manic episode. In his manifesto, he claims to have been planning his revenge for years. This may be true, or it may be the grandiose expression borne of mania. A person in mania could easily write a document of that length in a short amount of time. If is true that he was planning this rampage for years, then it was, fortunately for us, poorly executed. He stated that he was going to go to a sorority house and kill all the women inside, yet he had no real plan for accomplishing this. He didn’t even know how to get into the sorority house once he arrived. Instead of killing everyone inside, he killed two innocent bystanders who were not even members of that sorority. As the rampage proceeded, it became more disorganized, ending with his suicide.

He uploaded a large number of repetitive videos in a short amount of time, another sign of mania. We have no evidence other than what he states in his videos and manifesto that he was a virgin, that he was suffering for years in a deep rage, nor has anyone come forward with any proof of his hatred that he talks about. We have no way of knowing for sure how long he had truly harbored these thoughts. One of his childhood friends mentioned in the manifesto expressed genuine surprise that the killer had these feelings.

When a person experiences mania or mixed mania, thought processes become derailed. They become irritable and paranoid. Time perception is disturbed. The level of activity is increased, however this activity is not well organized. His manifesto has been quoted widely, with the implication that what he said should be accepted as fact. He says he planned it for years, then it must mean he was planning this for years. However, it is just as likely he was planning it for a much shorter time, and his report of years was the result of the same psychotic thinking that motivated his rampage. He talks about previous attacks on women and couples, and blames a high school crush for his “retribution.” Again, we have no real proof that he really carried out these attacks. Nor is there any proof he really did harbor hatred against his childhood crush for so many years.

I am not his psychiatrist, and I am not claiming that my assessment is accurate. However, if it is true that his rampage was the result of a psychotic break or manic episode, then shame on all of us. These episodes are easily treated in the inpatient units. In the amount of time since the killer first posted his videos on YouTube, in April, here at our lowly rural behavioral health unit (BHU) we have successfully treated over a dozen young men experiencing either a manic or psychotic episode. Many of these young men were brought in by law enforcement officers. Every one of us should be grateful to these officers for doing their job to keep us all safe.
Click on this link for a great reference guide if a family is looking at the process of involuntary procedures in Missouri.

Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.

Please visit Wexler Family Psychiatry to schedule an appointment.


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Oct 05

College students and mental health

By Dr. Micaela Wexler
As a family psychiatrist, I have noticed this is the time of the semester when college students first face mental health challenges. These can include issues like homesickness, anxiety about exams, alcohol abuse, difficulty with focus and concentration, romantic break ups, roommate conflicts, insomnia and time management challenges. Though these are common, and not considered serious, they can interfere with a student’s progress. These issues are easily treated, and should be addressed by students and the people in charge of supporting them.

The mental stress that is part of the college experience can trigger episodes of serious mental disorders. It is at this time of the semester, when first exam grades have been posted and class withdrawal deadlines are approaching that students with issues like bipolar mood disorder, eating disorders, severe OCD, or more rarely, psychoses or delusional disorders are especially overwhelmed. A significant number of people with these disorders are not diagnosed until early adulthood, so if they are in college when the first episode occurs, they usually find themselves alone, without psychiatric care.

It has become routine on college campus for a review of mental health services to be part of new student orientation. Many colleges offer a number of free counseling sessions to every student. However, when students are faced with an actual mental health crises, their thinking process tends to be derailed and they don’t always know what do to. The most frustrating aspect of mental health care is that oftentimes, even people with severe mental illness may fail to recognize they are at risk and need help.

College students can play an important role when it comes to mental health by being attentive to their peers. Students should trust their instincts and take action when they sense a fellow student is under mental duress.

All students should know the warning signs for suicide. An easy mnemonic has been developed by the American Association of Suicidology: IS PATH WARM (Ideation, Substance Abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawal, Anger, Recklessness, Mood Swings). Students should know where to turn for immediate help if they suspect a fellow student is suicidal.

Students do not need to sense a problem is as serious as suicide to take action. If a fellow student seems down, or has stopped eating, is losing or gaining weight rapidly, or getting intoxicated frequently, that person may need help. Help can take many forms. A student could ask a peer directly, “are you ok?” If that feels awkward, a student could bring up the topic in a general way, ie, by talking about something they heard in class, or on the news, ie, “I heard that severe stress in college can trigger (an eating disorder, a drinking problem, severe OCD, hearing voices). What do you think?”

Or, a student could say to a peer, “you have seemed really worried lately. Would you like to talk about it?”

A student should not take it upon themselves to be the sole source of support for a student in need. Before approaching the student in need, a college student should speak to a professor, resident assistant, a mental health provider, just in case the situation is more serious. This can easily be done in a way that protects the other student’s privacy and dignity.

On the other hand, talking with other students about the student having problems without ever offering support to the person who is depressed or behaving erratically is not only unkind, but potentially dangerous. There is still a great deal of stigma regarding mental health issues, and contributing to this should NOT be part of the college experience. Nowadays there are effective treatments for even the most serious of mental health challenges. Taking positive action in the face of mental duress can be rewarding for college students. Preventing mental health tragedies is something which will enhance the college experience for everyone involved.

Sep 10

“Suicide prevention starts with you.”

By Dr. Micaela Wexler
Whenever I say this to people, they think I mean for them to help prevent suicide in other people. They immediately think about their families, friends, co-workers, children, spouses. In most cases, they are eager for tips on how to join in the fight to stop suicide.

“I mean YOU, specifically. Suicide prevention starts with YOU.”

Suicide is something that can happen to anyone. While we all need to help each other in preventing this tragedy, you can’t prevent someone else from committing suicide unless you prevent yourself from committing suicide.

“Well, that’s easy,” people tell me, “I don’t believe in suicide. Suicide is a selfish act; I would never do that to my loved ones.”

It turns out that people who commit suicide were once just like you: they didn’t believe in suicide. Like you, they had children, parents and friends. They loved them very much and did not want to hurt them. Just like you, they had religious beliefs that once gave them strength and comfort. They had goals and dreams and plans. They had crushes. They had love affairs. They had marriages.

So, to prevent suicide, you have to start by examining yourself.

Do you find yourself doing things you never did before like yelling at the grocery checkout person? Are you snapping at your husband? Does your best friend suddenly make you fly into a rage? Are you drinking more than you ever did? Are you in a financial crisis you feel you have no way out of?

Do you find yourself being careless about your safety: being less careful about locking doors at night; not slowing down for yellow lights; driving recklessly on the freeway?

Many people have these thoughts. That doesn’t mean you should ignore their seriousness. Letting thoughts like these pile up can put you on the road to developing a serious depressive episode. That is the most common reason for suicide.

If you are having these thoughts, then you are not taking care of yourself. You are not taking time to enjoy life. You are losing sight of your dreams and goals. Maybe you are not spending enough time with friends who appreciate you. Maybe you are working too much, at the expense of socializing and exercising.

You can do things immediately if any of these situations pertain to you. Right now, take a deep breath and think of something positive you will do for yourself TODAY. It can be something simple like taking a walk, calling a good friend, making plans to go watch a movie, buying yourself a new song, playing a computer game.

Look at your schedule and see what items are on it that make you feel good. How can you add more? You may not be able to get out of your financial crisis, but you can probably find someone to talk to, either about your problem, or something completely unrelated, to take your mind off your crisis.

If you are having the thoughts I’ve mentioned, this is a sign you need to find time to reflect on what is good about you and your life; you need to make it a DAILY practice; you need to refocus on your hopes and dreams. You need to reach out to loved ones, clergy, maybe a therapist, or the employee assistance program.

There are some thoughts that will require much more than than what you can do alone. There are thoughts that are a sign of something serious that needs immediate professional attention.

Do you feel you have no purpose in life? Do you feel completely hopeless? Do you ever find yourself having thoughts about what it would be like to be dead? Do you find yourself thinking that people would be better off without you in their lives? Do you find yourself going beyond simply not slowing down for yellow lights, and actually running red lights? Do find yourself wondering what it would be like to go toppling off the overpass? Do you notice you are preoccupied with the after life?

These are all thoughts that are a sign of serious suicide risk. Do not ignore this. There are several options for immediate help, from calling 911 and talking to the police, to calling 1-800-273-TALK or 1-800-SUICIDE (1-800-273-8255, 1-800-784-3433) or going to the emergency room. Either one of these options will lead to a trained professional who can help determine the type of help you need immediately.

Nine out of ten people who commit suicide had a diagnosable mental disorder. But, only THREE out of 10 people who die by suicide received mental health care in the year prior to their suicide.

So, start preventing suicide by taking a look at yourself. Because, trust me, we need you around.