Providentia

Jails as Mental Health Centres

There are more than a million prison and jail inmates in the United States who have mental illness given the harsh cutbacks in funding for community support programs. A paper from a recent issue of the Journal of Trauma and Dissociation discusses the growing need for 24 hour mental health units within prisons and jails to handle this spiralling demand. The authors contend that mental illnes has been 're-criminalized' due to the incidence of related support issues such as physical and/or sexual abuse, parental substance dependence, and parental incarceration. Prisons and jails most often do not provide services for this highly traumatized population or recognize the need for such services. Prisons are not hospitals and should not be regarded as suitable replacements for mental health facilities. The authors follow up by reporting on problems with mental health care in prisons, and on several attempts to establish 'trauma-aware' care within the legal system.

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Why Aren't Some AIDS Patients Getting Treatment?

In a recently released study by the British Columbia Centre for Excellence in HIV-AIDS, an alarming forty per cent of the people who died of HIV-AIDS in British Columbia never sought life-saving treatment even though it was free. The study examined more than 1,400 HIV-related deaths in British Columba between 1997 and 2005 and found that 567 people died without ever receiving antiretroviral treatment. In a statement by Dr. Julio Montaner, director of the centre, he notes that: "We have a problem. The treatments are available for free but something is wrong because the people that most need the treatment, they're not always accessing the treatment."

Low income is one of the most prominent factors associated with high AIDS mortality with residence in a poor neighbourhood being linked with reduced access to treatment. Other factors include lack of housing or transportation, mental illness, illegal activity and language barriers that play a role in an individual's ability to access treatment.

An estimated twenty-five per cent of those infected with HIV in Canada are not aware of their infection, according to the centre. While the centre distributes free antiretroviral medications to all eligible British Columbians through the provincewide Drug Treatment Program, funded by Pharmacare, ensuring access to treatment for all HIV patients remains an elusive goal.

"We have found that over the last several years there is a persistent number of people dying with HIV in our midst, where treatment and health care is supposed to be readily available," Montaner said.

He described typical examples including single mothers without access to child care resources and homeless, mentally ill drug addicts who are unaware of their HIV status.

Montaner further adds that the problem is that same across all of Canada and the percentage could even be worse in smaller communities where fewer resources are available.

Ken Buchanan, of the British Columbia Persons with AIDS Society, commented on the study by saying that the long-term solution is to bring some stability to the lives of HIV-AIDS sufferers. "For a person who is homeless, taking medications, even free medications, is pretty low in their priorities," he said.

He further warned that access to medication isn't enough since a person who begins treatment and doesn't maintain the proper dose regime will build up a resistance to the drugs and end up more likely to die.

While the centre currently has a proposal before the provincial government to form outreach teams that would take rapid-response testing to the most vulnerable and offer treatment, the presence of free health care may not be enough to address this problem,

"We need to bring the treatments to the people and we need to create the programs that are going to help these individuals to take the treatment. It is not only the ethical and human thing to do, he said, it's also better for society at large because it reduces HIV-related illnesses that drain the health care system. By treating these people we're doing what is right for them, we're doing what is right for the system and we're also going to decrease HIV transmission," Montaner said.

Previous research by the centre and by researchers in Taiwan showed a 50 per cent reduction in new HIV cases that due to access to antiretroviral therapy. The current treatment regimen of three or more antiretroviral drugs on a daily basis for life requires a very high level of adherence in order to be fully effective.

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Constance Kent

It was on June 30, 1860 when three-year old Francis Kent disappeared from his bedroom in the Kent family home near Frome, Somerset. His nurse, Elizabeth Gough, discovered early in the morning that Francis was missing from his bed and a search of the grounds was launched. Rather than alerting the local police, Francis' father, Samuel Kent, drove to the next county to report his son's disappearance and left others to continue the search. The discovery of Francis' body in an outside privy horrified the searchers. Not only had the boy's throat been cut (and his head nearly severed) but later evidence showed that Francis had been suffocated. When Jonathan Whicher, an inspector from Scotland Yard, was dispatched to investigate, he immediately focussed on two suspects who were brought before the Magistrates: the child's nurse, Elizabeth Gough and Francis' sixteen-year old half-sister, Constance. While Gough was cleared of any wrongdoing or motive, Constance was another story.

As one of the five surviving children born to Samuel's first marriage, Constance had little love for her stepmother. Mary Kent was the former family governess and had been Samuel's mistress while his first wife was still alive. Despite Whicher's suspicion that Constance had killed her half-brother as part of an elaborate revenge on her father and his second wife, the lack of evidence led to her release. Local outrage at Constance being accused permanently damaged Whicher's career and the murder stayed unsolved. A cloud of suspicion remained over the Kent family and Constance was later sent to a religious school in France.

In 1863, Constance attended St. Mary's School in Brighton and it was there, two years later, that she confessed to Francis' murder. Controversy still remains over how this confession was obtained. Reverend Arthur Wagner, principal of the school, approached the Home Office with a "handwritten confession" and insisted that Constance be tried for murder. The resulting trial was somewhat unusual since the only evidence was the confession itself and Wagner maintained that much of what Constance had told him could not be repeated in court due to the "seal of the confessional". Constance pled guilty and was sentenced to death after a sensational trial.

When objections were raised over the validity of the confession and whether Constance's father played a role in forcing the confession (he had been accused of murdering Francis himself in a fit of rage), Constance's sentence was changed to life imprisonment. She served twenty years in prison before her release in 1885. Constance then immigrated to Australia to be with her brother William and changed her name to Ruth Emilie Kaye. Qualifying as a nurse in 1892, she had a long nursing career (including serving as a Matron at a school for "wayward girls") and finally retired at the age of 88. Constance Kent/Ruth Emilie Kaye died on April 10, 1944 at the age of 100 and is buried in Australia.

What can we say about Constance Kent? If she did murder her brother, then it was the only act of violence that she ever committed in her long life (despite the efforts of some overly eager crime writers to link her to the Jack the Ripper murders that took place in London three years after her release from prison). If she made a false confession to protect her father or some other family member then she was remarkably loyal. She never recanted her confession despite outliving her father and virtually every other member of her family. The truth behind Francis' murder will likely never be known (but the mystery remains).

Head Injury and Substance Use in Teenagers

A paper published in the January 2008 issue of Journal of Pediatric Surgery contains the results of a study examining the role of drug and alcohol use in adolescents suffering from traumatic brain injuries. Using trauma registry data to identify adolescent blunt trauma victims between 2000 and 2005, demographic information, injury severity, length of hospital stay, and clinical outcomes were evaluated. Of the total number of adolescent patients sampled, 9.3% tested positive for drug and/or alcohol use (the mean age of toxicology-positive patients was 17.2 years). The most commonly detected drugs were cannabis (40%), alcohol (30%), and polysubstances (23%). Substance-positive patients were more likely to be comatose, to have more significant injuries, and require emergency operations than adolescent patients who did not test positive for substance use. Length of hospital stay was was also significantly longer. In terms of outcome, mortality was found to be significantly higher and functional independence was lower. The authors conclude that substance abuse was linked to injury severity, need for medical care, and poor medical outcome for adolescent blunt trauma victims.

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Bizarre Suicide by Psychiatrist Mimics Patient Death

It was on February 14 when staff members at Pavlov Mental Hospital in Kolkata, India discovered the body of Dr. Dipankar Choudhury in the hospital duty room. The 52-year old psychiatrist had apparently strangled himself by tying his muffler to the door handle. The circumstances under which the body was found was identical to a suicide that had been committed by one of his patients in early January. A colleague reported that Dr. Choudhury had been shaken by his patient's suicide but there is no indication that his own suicide was pre-planned.

While he had been visibly depressed in the weeks leading up to his suicide, it is not known if he was on medication at the time of his death. The body was discovered after his wife contacted to hospital to express her concern over a call that he had made to her that evening. An alert was sounded after the duty room was found locked from the inside.

He is survived by his wife and three children and had been working at Pavlov Mental Hospital for three years.

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Saving Ezra Pound

The end of World War II in 1945 was a time for celebration, but it was also a time of reckoning. While the Nuremberg trials for Nazi war criminals were still in the planning stage, legal proceedings against enemy collaborators were well underway. In Great Britain, the trial of William Joyce (a.k.a. Lord Haw-haw) for treason due to his Nazi propaganda broadcasts led to his execution in 1946. And then there was Ezra Pound...

As a major figure in 20th century poetry, Pound's expatriate life in Italy led to his becoming an advocate for the Axis powers. He opposed the war (particularly the involvement of the United States) and expressed his support for Mussolini and Fascism through numerous radio broadcasts and writings. Even after the United States entered the war, Pound continued to be active in Italian politics until being arrested by Italian partisans in 1945. His incarceration by American forces near Pisa (including 25 days in an open cage) led to a nervous breakdown. Only after the end of the war was Pound finally sent to the United States for trial but what happened then is still a matter of controversy. While being a world-renowned poet, Pound was also reviled for his anti-Semitic views and his role as a Fascist collaborator. Since treason was technically a capital offense at the time, Pound and his defence counsel had ample motivation to arrange a plea bargain stating that he was unfit to stand trial. There was absolutely no indication that Pound was actually suffering from any mental illness but the plea bargain was quickly accepted to avoid embarrassing publicity. It seemed likely that Pound and his attorneys were hoping that he could be released after public furor died down.

Unfortunately for Pound, this gambit backfired. He was sent to St. Elizabeth's Hospital in Washington, D.C. where he would spend the next thirteen years of his life. His treating psychiatrists seemed confused about what to do with him and it was only in 1953, after considerable prodding from the Justice Department, that a formal diagnosis was given: narcissistic personality disorder. Despite the fact that he was never diagnosed as suffering from a major mental illness, Pound continued to be held. There is also some controversy over whether Pound received special treatment while in hospital since he was able to continue with his literary efforts (he would write three books),receive numerous visits from family members and fellow writers, and even engage in conjugal visits with his wife (not to mention his mistress). While in hospital, Pound continued to have an influence on a whole generation of new writers. Despite being allowed some freedom to pursue his writing, Pound hated his hospital stay and depended on his frequent visitors to keep him sane.

Only after numerous appeals from his fellow writers (including the poet Robert Frost) was Pound finally released in 1958 into the custody of his wife, Dorothy. Interviewed after his release, he gave the famous quip that "all America is a lunatic asylum" and returned to Italy to live for the rest of his life. Pound would continue to write avidly but lived as a near-recluse with his long-time mistress, Olga Rudge (he and Dorothy separated after their return to Italy). While he became a little less rigid in his declining years and disavowed many of his anti-Semitic views, he remained largely unapologetic to the very end. Ezra Pound died in 1972, just after celebrating his 87th birthday and is buried in San Michele Cemetery on the island of San Giorgio Maggiore near Venice.

What are we to make of this case? Critics of psychiatry often tend to paint Pound as a victim of psychiatric abuse while others regard him as a traitor who managed to escape justice. Ezra Pound was not a sympathetic figure but his 13-year incarceration in a mental hospital remains a graphic example of how psychiatric hospitals can be used to "warehouse" people regardless of their actual mental status. It is a misuse of psychiatric hospitals that continues to occur in too many countries around the world.

Is There a Jerusalem Syndrome?

Since at least the 1930s, mental health professionals in the city of Jerusalem have attested to the existence of a peculiar syndrome affecting some first-time visitors. Referred to as the Jerusalem syndrome, it is described as an intense religious psychosis characterized by delusions, obsessive ideas, or other psychotic symptoms that can affect first-time visitors to the city and can quickly resolve in a matter of weeks. There is a suggested typology of Jerusalem syndrome episodes based on whether there is a preexisting psychiatric history or idiosyncratic ideation involved.

Case histories that have been reported include one individual, who was observed to be dressed in a white tunic and wearing a gilded crown on his head welcomes tourists and pilgrims on their way to the Wailing Wall and proclaiming himself as King David. Being the psalmist, he held a lyre and sang psalms accompanied by occasional preaching. Another case involved a self-proclaimed "messiah" who was observed to guard the entry to Jerusalem and calling on all sinners to repent as he claimed the doomsday is near.  Another individual referred to himself as "Samson" and attempted to move the giant stones of the Wailing Wall "to the right place". After fighting down policemen who tried to interfere, "Samson" was taken to the Kfar Shaul Psychiatric Hospital in Jerusalem where he was treated and later released. Research into Jerusalem Syndrome has indicated that 1200 tourists diagnosed with the syndrome were admitted to the hospital over the period from 1980 to 1993. An estimated 100 cases are diagnosed each year.

While episodes of Jerusalem syndrome have been observed in Christians and Jews of different denominations, there is no consistent pattern noted. The term, Jerusalem syndrome, has come under dispute as similar pathology has been observed in pilgrims visiting other religious sites, including Rome and Mecca.

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Police Estimate 17,000 Victims of Honour Violence in Great Britan Yearly

A spokesperson from the Association of Chief Police Officers (ACPO) reported that an estimated 17,000 cases of honour-related violence occur in Great Britain annually. The association also stated that figures relating to forced marriages are the "tip of the iceberg". The women and girls who are subjected to forced marriages, kidnappings, sexual assaults, beatings and even murder by relatives determined to uphold "family honour" may be up to 35 times higher than official figures suggest. Children as young as 11 have been sent abroad to be married, which has prompted the Foreign and Commonwealth Office to call on British consular staff in Bangladesh, India and Pakistan to take more action to identify and help British citizens believed to be the victims of forced marriages in recent years. The British Home Office is preparing action to address "honour" crimes by improving the response of police and other agencies and to encourage victims to come forward to receive needed support. New legislation is also being prepared to enable courts to tackle forced marriages.

Commander Steve Allen, head of ACPO's honour-based violence unit, is reported as saying that the actual number of honour victims is "massively unreported". He states that approximately 500 cases are dealt with each year and further adds that "If the generally accepted statistic is that a victim will suffer 35 experiences of domestic violence before they report, then I suspect if you multiplied our reporting by 35 times you may be somewhere near where people's experience is at." He made these comments to the House of Commons last week, following a series of gruesome murders and attacks on British women by their relatives.

The majority of victims of honour violence remain reluctant to come forward due to fear of retribution and perceived lack of community-based support. Young girls have gone missing from school registers and are said to be home-schooled while actually being taken out of the country to be married abroad. Support agencies report bring back at least three girls a week from Islamabad as victims of forced marriage. The British Government's Forced Marriage Unit (FMU) reported handling approximately 400 cases last year – 167 of them leading to young Britons being helped back to the UK to escape unwanted partners overseas. Home Office figures show that 15 per cent of cases involve men and boys.

Almost all victims of the most extreme crimes are women, killed in half of cases by their own husbands. Sometimes murders are carried out by other male relatives, or even assassins hired by family members. The psychological toll on women facing honour violence is considerable. Women aged 16 to 24 from Pakistani, Indian and Bangladeshi backgrounds are three times more likely to kill themselves than the national average for women of their age. A report published by the Centre for Social Cohesion found that many women felt unable to defy their families and therefore "suffer violence, abuse, depression, anxiety and other psychological problems that can lead to self-harm, schizophrenia and suicide". Advocates accuse the British government of not "taking honour crime seriously. Until this happens, the ideas of honour which perpetuate this violence will continue to be passed on through generations."

While most honour killings appear to occur in Muslim countries, cases have been reported in South Asian cultures including Hindu and Sikh communities in Canada, Denmark, Germany and the United States as well as in South America.

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For the Amnesty International link.

Tripping Out, Part II

There is no way of doing proper justice to the full range of research into LSD that occurred during the two decades following its discovery in the 1940s although some prominent pioneers tend to stand out. One of these early pioneers was Dr. Humphry Osmond. Born in 1917 in Surrey, England, Osmond trained to become a psychiatrist and later became a Senior Registrar at a psychiatric unit at St. George's Hospital in London. With his colleague John Smithies, he began researching the effects of mescaline on the human body and became one of the early advocates for a biochemical explanation for schizophrenia. Given the strong Freudian bias among British psychiatrists during that period, Osmond's determination to continue with his research meant that he would need to leave Great Britain altogether. Answering an advertisement in the Lancet for a deputy director of psychiatry at a Canadian mental hospital in Weyburn, Saskatchewan, Osmond and his family moved to Canada in 1951.

Within a year of arriving in Canada, Osmond launched his biochemical research program and joined forces with another early pioneer, Abram Hoffer. As a Canadian psychiatrist who had been hired as a research psychiatrist by the Saskatchewan department of Public Health, Hoffer had a keen interest in the biochemical roots of schizophrenia and quickly recognized the importance of Osmond's mescaline experiments. They began to work together and soon discovered that LSD was an even better drug than mescaline in producing psychotic symptoms in normal test subjects. Osmond and Hoffer decided to explore the therapeutic value of LSD in modifying behaviour and settled on alcoholics as test subjects. The hypothesis that guided them was straightforward enough: since research subjects reported increased self-awareness after taking LSD, could alcoholics develop new insight into their drinking as well? They further argued that the delirium produced by LSD in many ways resembled the experience of delirium tremens in alcoholics drying out from alcohol. If the experience of delirium tremens often forced alcoholics to accept that they had "hit bottom", could LSD delirium produce a similar outcome? In 1953, Osmond and Hoffer tested the effects of LSD treatment on two chronic alcoholic patients at the Saskatchewan Mental Hospital in Weyburn, and reported an astonishing 50 percent success rate. Osmond was emphatic in stressing that the key to their success was not LSD but rather the "insight" that the LSD provided. A second study published in 1958 involving 24 patients at University Hospital in Saskatoon also found that 50 per cent of the patients reported either total abstention or at least significant reduction in drinking over a three year period. Unfortunately, the highly subjective nature of LSD use and the difficulties involved in replicating Osmond and Hoffer's results made their colleagues reluctant to accept their conclusions. It was also noted that a minority of patients taking LSD reported negative experiences although these "bad trips" could be mitigated through the use of empathetic staff. Osmond and Hoffer would go on to treat hundreds of alcoholics under carefully controlled conditons.

The Addiction Research Foundation in Toronto (now part of the Centre for Addiction and Mental Health) challenged Osmond and Hoffer's research by questioning their methodology, particularly the lack of proper controls. ARF researchers, Reginald Smart and Thomas Storm, conducted their own LSD study in which patients were either blindfolded or restrained to control for the effect of additional stimuli that might bias the research findings. Their results were challenged by Osmond in turn and he questioned the rigidity of the methodology that ARF used in their study. A research study by Weyburn psychiatrist Sven Jensen was published in 1962 that compared alcoholics who received LSD treatment with patients receiving group or individual treatment. Jensen found that 38 of the 58 patients who had received LSD remained abstinent over the follow-up period compared to only a small minority of patients who had received conventional treatment.

While the controversy was raging, a moral panic was brewing elsewhere. The growing use of LSD as a recreational drug, aided by counterculture gurus such as Timothy Leary and Richard Alpert (a.k.a. Ram Dass), as well as its role in the student activist movement of the 1960s led to hysterical denunciations of the dangers resulting from rampant LSD use. Humphry Osmond may have unintentionally fanned the hysteria by his own actions (not only did he coin the word "psychedelic" but he was also the one to introduce Aldous Huxley to mescaline and LSD in the 1950s). By 1966, LSD was on the FDA's list of illegal narcotics and Sandoz Pharmaceutical Company (the only legal provider of the drug) voluntarily ceased production. LSD research was subsequently banned across North America by 1968.

And so it stands. Humphry Osmond died in 2004 after a long and illustrious career. Abram Hoffer remains active in the highly controversial field of orthomolecular treatment for schizophrenia. Alfred Hoffman, the Swiss chemist who started it all, is still living and continues to be frustrated by the worldwide prohibition on his discovery. While he concedes that LSD can be potentially dangerous, he also stresses its therapeutic value as reported by researchers such as Osmond and Hoffer.

Could LSD have developed into a viable treatment for alcoholism if events had gone differently? The use of MDMA ("ecstasy") in therapy has generated considerable interest but the current political climate probably ensures that LSD will stay illegal for the foreseeable future.

*A hat tip to Dr. Erika Dyck of the University of Alberta for kindly providing me with reprints of her publications on this fascinating topic.

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Does Gender Affect Schizophrenia?

Are there important differences in men and women suffering from schizophrenia? A paper published in a recent issue of Psychopharmacology Bulletin (2007:40) seems to suggest that there are. Women with schizophrenia tend to differ from males by having better functioning before the onset of psychotic symptoms, a later age at onset, a distinct symptom profile and better course of illness, and different structural brain abnormalities and cognitive deficits. Additionally, premenopausal women appear to have a superior response to typical antipsychotics compared to men and postmenopausal women. These gender differences appear to stem from the connection between hormonal and psychosocial factors. Estrogen in particular may play a protective role in women with schizophrenia and account for some of the gender differences observed in the disorder. Despite the potential benefit of estrogen in this population, women with schizophrenia appear to be at risk for hormonal diseases, either due to side effects from antipsychotic medication or, possibly, as a result of the illness itself. The authors stress the need for more research to examine the role for hormonal therapies in women with schizophrenia and gender differences in how antipsychotic medications work.

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