Mass Shootings, The Emerging Unfortunate Truths and Dilemmas

I felt it was time to share my thoughts on the mass shootings phenomenon that has been occurring to the dismay and horror of all of us over the last several years. My memory on this is somewhat longer than most people’s because of my profession as a psychiatrist and because I have been following this issue for now over twenty years when the first “modern” shootings started and the first was of school shootings by minors starting nearly two decades. This does not mean mass shooting have not occurred before in history as any internet search engine entry of “history of mass shootings” will give new reports and articles on shootings going back many many decades, eclipsing by far all our current lifespans.

I have seen as a psychiatrists people who have done isolated shootings very early in my training and early in my career after residency training. All of them were shootings in the singular or in pairs or more family members or persons known and close to the shooter/murderer. The first was an estranged young high school student who shot a supposed girlfriend he had an imaginary of delusional fixation on, and who finally jilted him at school, which was the trigger for his shooting her outside of school fortunately. He fit the now current profile we hear about in many of these cases, a younger, white loner male who is known by almost no one, a marginal student, on the fringes of almost all social circles in school and who suffers a traumatic loss and which constitutes the apparent motivating “last straw” or trigger for the murderous act which seems to come out of nowhere. As with at least some of the recent young white male shooters, he had had no contact with any sphere of mental health services and his family was certainly not aware of what was going on with him. Which leads to one of the central issues with many of these shooters, they convey their intentions usually to no one clearly though some of them display very disturbed, aberrant, angry, paranoid views toward one or more social groups they rant about and blame for various and sundry personal or national ills. Since the youths who become these murderous shooters, they have lived less long and have consequently displayed or entertained these issues for shorter periods of time, though in some of them by the time they reach their later teen or young adult years, it may have really been going on in their thoughts for several years. In the cases of the adult shooters, it seems to fall into two time frames, some for many years, in some for most of their adulthood with only hints conveyed to others rarely in the form of racial or ethnic group hatreds or “odd” ideas, that they do not expand upon long or often enough to raise alarm in their work colleagues or families if they are not total loners. The other class is the impulse shooter who usually is confined to giving way and losing control of murderous anger suddenly in reaction to a sudden loss, such as a job, rejection by a spouse with separation (usually a wife who leaves). These men then stalk their estranged wives, develop or increase their previous paranoid ideas that they wives are and have been cheating on them, though many or most of them have surveilled their wives so closely for so long with such sophistication, nowadays even planting secretly GDS directional instruments in the wives’ cars to track their driving patterns and destination, being convinced they will surely catch them in an affair. Also they typically, record  their wives’ cars’ mileage constantly, often follow them in their own cars, or do not permit them to drive as part of the over the top irrational jealousy and controlling behaviors toward their wives, in effect, keeping them captive, perhaps a milder subset that is related to though milder than the serial killers who capture women, torture them, but keep them in captivity as the case in Cleveland with the fellow who kept three women hostage for 10 years or so. Those men usually kill their spouses, and sometime qualify as mass shooters, which now is defined variously as killing two or three persons at once, though most authorities and experts still hold to the older threshold of at least three persons. An example would be the man in Minnesota who accosted his estranged wife in the beauty shop across from the large mall, shot and killed her, and killed one or more other women before turning his gun on himself. His shooting shows how indiscriminant the murderous rage can be as after he shot his wife which one would assume was his primary motive, intention and target, he shot, wounded and killed other women who just happened to be in shop at the time. Others of these men will not only shoot their estranged wives, but also their children, their own parents,-aut and/or their wives’ parents and thus qualify as “mass shooters.”

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Bring Back The Asylum? Really?

This article will discuss the surprising but necessary and growing realization in this country that in order to adequate repair our broken national mental health care delivery system, we have to “bring back the asylums.” Instead of continuing to downsize and abolish inpatient beds, and close more and more state hospitals, we need more beds, more specialized units and more new, modern replacement state hospitals to replace our ageing physical plants of state hospitals that are on average, almost all over 100 years old!

I must also apprise/warn the reader that I have violated the big rule of blogging that I have read in every tutorial on blogging in the last three years, to keep your piece to say, 300-500 words maximum. I have ten-tupled that out of necessity to cover this complex and controversial subject fairly and adequately. I do not believe the batted about insulting Internet based concept that suddenly all American Internet readers have suddenly developed incredibly short attention spans. The blogging books and authorities all would hold me up, I am sure, as the Greatest Violator of Blogging Rules Ever. I would answer that if you are not interested in the crisis of mental health care, and/or mental health reform in this country, quit now, stop reading this piece, save yourself time and do something that fits and pleases you better. I will not mind. But if you are, I would hope you will find this piece informative, motivating and encouraging. I do not write from a pessimist’s heart, and am not the old character from the cartoon strip of Al Capp’s, Little Abner, now long out of print and unknown to anyone under 40 years old or so; this character was called “Joe #@?!” or something like that. He was a total gloom and doom guy, worse than Eyore of Winnie the Pooh. He was illustrated so well pictorially by Al Capp to give any reader of the comic strip an immediate recognition of this character’s constant and unfailing pessimism and even constant expectation that misfortune was waiting for him at any second, by drawing with a little black cloud just above his head that was already raining on him and no one else wherever he went. I am hoping to write and promote change in the opposite, optimistic, we can gradually make things better mode. And fortunately in my state of practice in North Carolina, no matter our present hurdles, we are working diligently on them, I think in the last few years we have turned a number of big policy and implementation corners, and I am proud of this state’s efforts under very very adverse circumstances. I also hope that by writing from that perspective, and by picking up and publicizing in my own small way, successes, victories and advances I find through my professional collegial grapevine of four decades of colleagues from my training years, different places I have practiced, and the wonders of my cool little Google Internet keyword army of helpful search bots, I can spread some good news of mental health reform efforts in other locales that are also fostering improvement and progress against the daunting odds and difficulties we face commonly all over this country. So get your favorite beverage, get you thinking and pondering cap on, and undertake to read [in as many sittings as it takes] this massive blog “missal” on “bringing back the state hospitals,” not exactly a popular or politically correct concept perhaps these days.

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Heroin We Go Again, Deaths are Up, Up, Up

It seem to the casual observer, and I will include myself in that category on questions much bigger than me often, that in the War on Drugs, it is like the county fair “Whack-a-Mole” game, where you hit on pop up mole head down into its hole and another pops up over and over. With drugs we have still a plethora of illicit more damaging than every agents available, but as soon as we may progress on one drug of abuse’s “front,” another bounces up into increased availability to take its place for a while. And so  it goes with marijuana and meth, interdiction has been seizing more and more in the last few years and now heroin supplies have surged again becoming every  more obtainable again on the streets. One factor sadly is that a few years ago the American military had to make the tactical decision to stop the eradication effort on the poppy plant on the growing high planes of Afghanistan to save that country’s local economies, and to “win the hearts of the people,” the old concept from many previous wars, made most ‘popular’ in the Vietnam Conflict/War. Heroin is showing up again everywhere, the streets, points of interdiction and seizure, and in the ERs across the country.

An October 3, 2014 report “Increases in Heroin Overdose Deaths–28 States, 2010 to 2012,”  from the venerable CDC’s weekly mortality and morbidity report, the MMWR showed the increase in heroin to be quite real with data covering 56% of the country’s population showing in the first line that the prescription drug abuse and overdose epidemic 1999-2010 has been massive, stating: “Nationally, death rates from prescription opioid pain reliever (OPR) overdoses quadrupled during 1999–2010,” but then subtly noting that heroin OD death has increased at a slower rate during that period of time. The report then goes on the document step by statistical step, that heroin use and rate of overdose deaths increased after 2010 dramatically. It showed from data solicited from all states with responses from 28 states for just the two year period from 2010 till 2012, that “The death rate from heroin overdose doubled in the 28 states from 2010 to 2012, increasing from 1.0 to 2.1 per 100,000 population,” effectively doubling in that short of a period of time! Further the report found statistically and accurately that heroin overdose deaths increased nationally in every age demographic, not just the young adult segment of typically the early 20’s to mid thirties, and that the OD death rates increased also in females a trend not always seen. The report goes on the compare in effect time periods of heroin high rates of use with the current period and states telling: ” In a sample of heroin users in a treatment program, 75% of those who began opioid abuse after 2000 reported that their first regular opioid was a prescription drug. In contrast, among those who began use in the 1960s, more than 80% indicated that they initiated their abuse with heroin (8). Persons who initiated heroin use after 2000 have reported that heroin often is more readily accessible, less expensive, and offers a more potent high than prescription opioids.”

There was a national increase in heroin overdose deaths of at least 45% in the years 2009-2012; states had increases in the time period 2010-2012 of from 74% to 300%!!!

So it is clear the heroin scourge is with us again, proving sadly and tragically that history repeats itself,” that addictive waves of old drugs “come around again,”

I fear that each generation must learn its developmental lessons all over again for itself, such as how to study in school, how to get toilet trained, how to share with other kids in the sandbox, dropping out of school means economic serfdom or condemning yourself to the illegal underground economy, tattoos are hellishly painful and expensive to have removed by your friendly expensive dermatologist even with a laser when you realize they are dumb and keep you from getting hired sometimes, that binge drinking really is bad for you and not worth the pseudosocial rank it seems to afford you in your equally stupid peer group who fail their exams just like you did because of it, that prolifigate sex will eventually teach you an unwanted lesson, and working in a low level service job will not pay for all your “Tunes” and the expensive Nikes your mom and  pop used to buy for you in the old days, that your friend and apartment roommate will not pay the rent and steal you blind when you throw him out and then realize you cannot afford the rent by yourself…And that heroin will addict you and can very well kill you like it did Jerry Garcia of the Grateful Dead in 1995, who as bright as he was, was an absolute idiot when it came to heroin and speedballs, dying IN a treatment center and betraying his fan base to boot. [As an aside yesterday I viewed his last interview in ?August 1995 very shortly before his death, and he was high, loose, disorganized, funny but pathetic, an old man who had not learned anything…] At least David Crosby came to his senses reportedly when he needed a liver transplant and realized what he had done to himself, and Robert Downey so far has demonstrated the power and benefits of sustained recovery.

So our public education efforts on heroin will have to ramp up again at all levels, and the War on Heroin specifically will increase once again targeting the cartels and gangs and God knows who else. And hopefully the greedy legislators in this country in order to fulfill their mantra of renewed Voodoo economics so ably and foolishly tried again by Governor Sam Brownback in Kansas, will not seizure upon legalizing and taxing heroin to make up for their moronic self deluding state revenue reducing policies that result in the chaos now repeating itself in Kansas, the land of sucker legislators, disappearing revenues, huge new budget deficits in the cautious Heartland of America (Crazy California yes, but not rock steady sensible Kansas. And if the “good Governor’ destroys the economy there and sends it into bad bond rating territory because now deficit borrowing, self induced tax raises (oh my what the Republican Governors’ caucus think of him now?), no more best buddy status for him…then he can count himself as stimulating the underground economy and drug i.e., meth manufacture and sales, increasing sales and distribution of heroin, if the marginal folks have no where else to turn to work and we will replication of what has happened in white Appalachia repeats itself in the Heartland, which stereotypically and simplistically thinking, is almost “unthinkable.”

One of the most recent news reports, from NBC News, June 17, 2105 entitled “Drug Overdoses Spur Rise in Accidental Deaths,”  On the general level even, its statistics are startling: “drug overdose deaths have doubled in the last 14 years”; “drug overdoses killed 44,000 people in 2013” [more can car accidents!]; “more than half of these deaths, 51.8%” were related to our now well known prescription drug abuse  epidemic, “with more than 16,000 deaths related to prescription painkillers…” West Virginia, one of the chronically poorest and of recent years with the downturn in the coal and timber industries, has topped the list consistently for accidental drug overdoses in this country. Suicides, are still the second leading cause of injury deaths, accounting for 41,000 annually, while motor vehicle accidental related deaths are third with 33,000 but noticeably continue to decrease over time. I can remember when I was in my youth that MVAs killed on average 55,000 annually consistently UNTIL the great organization MADD, Mothers Against Drunk Driving, identified the main cause as drunk drivers, especially recidivist drunk drivers, and started the national pressure campaign and hastened the long needed legal and enforcement crackdown on drunk drivers, with longer prison sentences even without death involved, for repeat offenders. Well into this report comes the subtle point that heroin now again is making up a large part of accidental drug overdoses, and that again “Heroin use [is] on the upswing again.”

Don’t Let Your Kids Grow Up to be Cowboys, Or Play Football

Part of the above title is from the decades old popular tune by the late great Waylon Jennings, “Don’t Let Your Sons Grow Up To Be Cowboys,” which had a message its all own about the rough life and that reality was not as romantic as portrayed in the American myth of the cowboy and perhaps about his own life as well as a hard living, hard drinking country entertainer. I always wondered growing up what effect his not getting on the plane in the 1950’s with “The Big Bopper” and the equally great late Buddy Holly, that crashed and killed them, had on Waylon Jennings, the fact he accidentally avoided death. I thought even as a kid his music had a certain wistful, depressive undertone to it, rivaled only by a few other such singers and lyricists. My apologies to his spirit for commandeering his song title partly for this piece.

Since the death by shotgun blast aimed intentionally at his chest, by Dave Duerson over a decade ago, a former lineman for the St. Louis Cardinals (back then), there has been much controversy over the effect of head bashing and cranial trauma on football players, most of it focusing on the effects by the time one has reached the professional ranks as a young and pre-middle aged adult in one’s late 30’s when most pro footballers retire. Lineman, as I understand it, tend to play longer and have longer careers than running backs and maybe pass receivers who run, are more mobile in the specialty positions and far more likely to suffer “career ending” knee injuries much frequently earlier in their careers.

Dave Duerson knew something was badly wrong with him mentally and likely cognitively. He was reported to have complained of headaches, depressions that he could not shake, memory problems, awareness that his intellect was failing him, mood changes, i.e., anger outbursts that he could explain or control, but most of all apparently a growing persistent, unshakeable preoccupation with suicide. He apparently revealed almost none of this to close friends, associates, family, and I like everyone else have no idea whether he revealed these self witnessed changes to his physicians. In any case, he stunned the sports world when he committed suicide, left an explanatory note that he mandated his brain be donated to neurological science and studied for what he felt was wrong with him. It was immediately clear that his placement of the barrel of the shotgun he used to kill himself was intentionally placed on his chest to preserve his skull and brain for scientific study. His courageous, if one can use that term as I know there are many opposing viewpoints about the act of committing suicide itself, but sad death, put the football world on notice that nothing had before, that something bad was going on with head injuries and possible or likely later in life serious repercussions like dementia and mental changes. The NFL had had by that time an ongoing study following players after retirement and had an investigational neurologist heading up the long term follow up study. But it gradually became enmeshed in horrendously vitriolic controversy as being inadequate, having conflicts of interest with the head of the study being paid and retained by the NFL and perhaps not open to enough peer review, scientific scrutiny. The NFL maintained relative silence on the issue but the uproar grew and grew especially in the neurologic scientific, brain research communities and the head of the program resigned or was fired (who knows how these work behind closed PR doors, especially when they say the standard exit euphemism of “He wanted to spend more time with his family”).THe study commissioned was thoroughly revamped, restocked with different personnel from many disciplines and made independent of the NFL. The sports media speculated on the supposed reactions of the team owners’ whose buckets of gold could potentially be threatened etc.

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