Providentia

"Himalayan Viagra" Murders Yield Life Sentence

In alternative medicine, much like everything else in life, sex sells.  Which has let to a major market in traditional aphrodisiacs.    Although medications such as sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are routinely prescribed for erectile dysfunction these days, they actually do little for the libido.  To fill the gap, there is a flourishing trade in various traditional and non-traditional aphrodiacs which supposedly boost sexual desire (often as a result of the placebo effect).   Along with assorted herbal compounds including  Spanish Fly, arugula, saffron and ginseng,  various animal products with rumoured aphrodisiac properties have led to the extinction or near-extinction of different tiger and rhinoceros subspecies across much of Asia and Africa. 

While not as well known as other aphrodisiacs, the caterpillar fungus orphiocordyceps sinensis has developed a reputation all its own.  Primarily found in the Tibetan plateau bordering China, India, Nepal and Bhutan, the fungus germinates in several species of caterpillars found in the region.  After killing and mummifying the host, the parasitic fungus then grows from the caterpillar's forehead into a mushroom that is high prized for its medicinal properties.  Known as yarsagumba or yartsa gunbu in Tibet and dong chong xia cao in China, the mushroom has gained the informal nickname of
"Himalayan viagra" and is used for treating impotence and fatigue in traditional Chinese and Tibetan medicine.   Virtually unknown to Western medicine before 1993, yarsagumba gained international prominence during the Beijing National Games when several athletes breaking world records were found to be taking it.   

The growing demand for yarsagumba has made it a major source of income in rural Tibet.   Although the laborious work involved in hand collecting the fungi has limited actual production to an estimated 100 to 200 tons per year, the extreme demand leads hundreds of Tibetan traders to cross the border with Nepal illegally each year to buy yarsagumba for sale in China.  Since one kilogram can fetch as much as $10,000 US, local authorities set up a permit system to regulate yarsagumba production and outsiders are often banned from collecting the rare fungus.  

Unfortunately, with strong demand comes inevitable tension with local gangs protecting their territories from outside yarsagumba hunters.    In June 2009, seven men from Nepal's Gorkha region were murdered after crossing into the Annapurna mountain circuit to collect yarsagumba.   In what was apparently a case of vigilant justice, dozens of men from the remote village of Nar attacked their victims with sticks and knives and then threw their bodies into a deep mountain ravine.   Only two of the bodies have been successfully recovered while the rest have never been found.  It remains unclear whether the bodies are still in the ravine or have been removed and thrown in the river by villagers attempting to conceal the crime.

In what has turned out to be one of the largest murder cases in that region's history, more than eighty police officers were mobilized to carry out mass arrests.   Since the local jail wasn't large enough to hold all of the accused, a district education office in a local village was converted to a makeshift jail and seventeen defendants have since been released on bail.  The rest are being kept behind barbed wire and rely on family members to bring them food.  The case has brought financial hardship for the family members of the accused who say that all of the able-bodied men in their village have been arrested.    Samma Tsering, whose brother is being held, stated that, "our land is barren now.  There is no one to plough the fields so we haven't been able to grow anything for two years. Women who know how to do the men's work are somehow managing but most of them can't."  

For many of the families, the ploughing may never resume.  In a verdict that has received international publicity, six of the defendants have received life sentences for their role in the killings.  An additional thirteen villagers received two years in jail while the rest were acquitted.   According to a local court official, the six receiving life sentences were found to have participated in the murder directly while the others provided indirect help. 

In the meantime, the prosperity that yarsagumba cultivation has brought to the region is also turning out to be a curse.  As the demand for "Himalayan viagra" continues to foster competition for the rare fungus, violence remains a grim possibility.

For more information.

The Magnetic Doctor's Crime (Part 1)

It's still one of the most bizarre murder cases in New Orleans history.

When the charismatic "Dr. Eugene Etienne" moved into the scenic rooming-house 714 St. Peter Street in New Orleans' French Quarter in 1884, the fact that he spoke no English hardly seemed a barrier.  Since French was still widely spoken in the area, developing a clientele for his practice wasn't really a problem.  Although Franz Mesmer had died in 1815, interest in "animal magnetism" or, as Dr. Etienne called it, "magnetic physiology" was still strong enough to attract curious clients.   Advertising for new clients was largely restricted to Etienne distributing cards on street corners with the colourful slogan: "Let us look for the truth!  Let us do good! Let us be magnetized!   Dr. Eugene Etienne, 68 Rue St. Pierre".

Patients going to the rooming house where the good doctor lived quickly found his prominent shingle which read (in French):  "Searching for truth?  Doing it well?  Dr. Etienne, professor of magnetic physiology of Paris.  All maladies cured by magnetism.  Treatment at domicile".   His treatments often involved dosing his patients with chloroform to make them more susceptible to his "magnetic will".   If the patients didn't get any particular benefit from the sessions with Etienne, he didn't really harm them either.  Since his fees were quite reasonable, i.e., small, he had no shortage of clients who often returned for repeat sessions.  Not only was he a refined gentleman whose manners impressed his, mostly female, clients but he was an attractive man as well.  For male patients, he offered a cure for impotence and his virile appearance served as a testimonial to the cure's effectiveness.

While neighbours became used to his comings and goings, there was no indication that Dr. Etienne established any real roots in the community.   That changed in 1888 when he became friends with Jules Deitsch.  Deitsch, a carpenter who lived nearby, was similar to Etienne in many ways.  As a Parisian immigrant who had only lived in the United States for a few years, Deitsch spoke little English and naturally gravitated towards the cultured doctor whom he first saw as a patient.  As a firm believer in magnetic physiology and being homesick for Paris, Deitsch welcomed the chance to visit with Etienne and discuss French culture over a glass of wine.  Since Deitsch was a widower, he was worried about his two young daughters, Laurence, aged nine, and Juliette, who was twelve years old.  Juliette was a particular concern for him since she was extremely mature for her age and already attracting the interest of many of the local boys.

As his friendship with Dietsch grew,  Etienne began sharing many of the details of his life.  He confessed that his true name was Etienne Deschamps, that he had been part of a wealthy family, and that he had graduated from a Paris dental college.  After being disinherited by his family over unspecified "youthful excesses", Deschamps served in the Crimean War and later went into politics.  As a result of political pressure, he was forced to leave France for a while.    When his attempt to start a new life in Brazil failed (he blamed it on politics again), he returned to Paris where he discovered his "magnetic powers" and became fascinated with the occult.    Eventually forced out of France again (this time he blamed his family), he decided to resettle in New Orleans as part of a plan to make himself wealthy.  This was when he made Jules Deitsch an interesting chance to become wealthy as well. 

According to Deschamps, his magnetic powers could do far more than heal the sick.    He was also hoping to find the lost treasure of the notorious pirate, Jean Lafitte.  Stories of the enormous treasure that Lafitte had buried somewhere in what is now known as the Barataria Preserve near New Orleans had already become the stuff of legend.   While Deschamps had been searching for the treasure, he couldn't find it alone.  For the next part of his scheme, he needed a young virgin to act as a medium to help him locate the treasure using his magnetic powers.  He suggested that Juliette would be perfect and that both he and her father could become wealthy after the treasure was located. Deitsch was intrigued by the plan and agreed to let Juliette participate.  That the plan involved Deschamps dosing Juliette with liberal doses of chloroform while conducting private "mediumship" sessions with her didn't seem to set off any alarm bells for him (Deschamps was in his seventies, after all).  While chloroform was still relatively new and stories of potential problems with its unregulated use were already circulating, Dietsch had no real concerns about Juliette.  Deschamps was a doctor, wasn't he?

Over the next few weeks, Deschamps spent considerable time with Laurence and Juliette and even brought them to his room where he plied them with candy and fresh fruit.  He also took Juliette on trips throughout the Barataria swamplands to prepare her for her role in finding Lafitte's treasure.  Due to Deitsch's growing concern about Juliette becoming involved with the local boys, he encouraged her to spend as much time with Deschamps as possible.  Neigbours seeing Deschamps with the two girls often thought that they were his daughters and Deschamps did nothing to correct them.  In the meantime, the private sessions in Deschamps room at the boarding-house continued.

On January 30, 1889, Jules Deitsch was interrupted at work by his elderly mother.  Laurence had come home and was crying hysterically.  When Deitsch came home to investigate, he found a strange bundle on the floor next to her bed.  The bundle contained books that belonged to Deschamps.   When Deitsch pressed his daughter to tell him what had happened to Juliette, all that she could say was that, "The doctor told me that Juliette is asleep and that he is going to die".    Hearing this, he grabbed Laurence's hand and half-carried her to the Peter Street rooming house.  After banging on the door, he awakened one of Deschamps' neighbours, who also happened to be a night watchman.   When neither of them got a response, they went to the Third Precinct Station and got three policemen to come back with them and they were finally able to enter Deschamps' room after obtaining a duplicate key from the landlady.

The scene that they found was certainly bizarre.  The room looked as if it hadn't been cleaned in months with books and papers scattered all over.  The fireplace was filled with charred papers that were still giving off smoke and there was a single lit candle on the mantle.  On the bed were Deschamps and Juliette, both naked with her head on his chest.  Although Juliette was dead, Deschamps was still alive although he had stabbed himself in the chest four times with a sharp dental instrument.  When Deschamps opened his eyes, he told the police, in French, "I meant to die".   He then lost consci0usness again.  After calling for an ambulance, the police searched the room and found a series of letters in a neat pile.  They were all addressed to Dr. Deschamps and had apparently been written by Juliette.

To be continued.

 

 

 

 

 

 

Using Mentoring Programs to Combat PTSD in Veterans

Three years ago the U.S. Department of Veterans Affairs (VA) charged the National Center for PTSD (NCPTSD) to develop a mentoring program to train directors of specialized PTSD clinical programs in effective management skills. There were three reasons for this. First, the number of veterans from the Afghanistan and Iraq conflicts coming to the VA for PTSD treatment was rapidly increasing. Second, a major augmentation in mental health staffing had brought many new clinicians to the VA who were unfamiliar with war-zone–related PTSD and with the VA system of care at a time of changing administrative requirements. Third, the clinical complexity of these veterans required additional mentoring because their PTSD was often associated with depression, mild traumatic brain injury, substance use, chronic pain, aggressive behavior, and/or insomnia. The resulting PTSD Mentoring Program created a national network of program directors to disseminate and implement best management practices by supporting local experts in their mentoring of other VA PTSD program directors. A recent article published in Psychological Trauma: Theory, Research, Practice, and Policy describes the implementation of the PTSD Mentoring Program and examines methods of how other programs can successfully use and adapt the mentoring model. A description of what is working and where obstacles still exist for the program is provided. The authors' experience with the program supports the use of peer mentoring as a method to offer educational training on trauma in different settings and using different modalities.

For the abstract.

Is There a Fentanyl Epidemic?

When Paul Janssen first synthesized the narcotic analgesic known as fentanyl in 1959, he intended the powerful mu-opioid agonist to be a radical new treatment for treating acute pain in cancer patients.  Far more powerful than morphine, fentanyl was first marketed as an intravenous anesthetic under the brand name, Sublimaze, by his company (now part of the Johnson and Johnson corporation).   As a fast-acting analgesic agent which passed out of the system rapidly, fentanyl quickly inspired a variety of analogues including sufentanil, alfentanil, and lofentanil.   The 1990s ushered in a new generation of fentanyl derivatives designed to improve quality of life in palliative care patients.  Along with the familiar intravenous form, fentanyl doses could also be delivered in the form of transdermal patches, lollipops (sold under the brand name of Actiq) and buccal tablets (Fentora).    As the most widely used synthetic opioid in clinical settings, demand has far exceeded available supply and there is currently a fentanyl shortage as a result.    Despite adverse side effects including nausea, diarrhea, breathing problems and, in rare cases, aphasia, fentanyl is still regarded as being safer than morphine despite concerns over potential withdrawal effects.

Far more worrying is fentanyl's growing appeal as a street drug.  Much like morphine, heroin, and other opioids, fentanyl works by binding to the body's opiate receptors and driving up dopamine levels which can lead to feelings of euphoria and relaxation.  While the "high" produced by fentanyl is less intense than heroin, its far greater potency makes it more dangerous, especially given the risk of respiratory distress and fatal overdoses.  Since the mid-1970s, transdermal fentanyl patches have been available on the black market under street names such as "Apache", "China girl", "China white", "murder", and "Tango and Cash".   Despite attempts by drug manufacturers to adapt fentanyl patches to make removing the drug content more difficult, fentanyl abusers can still get a high through smoking, snorting, injecting, and even eating the patches directly.   The number of fentanyl deaths has risen sharply over the past twenty years although available statistics largely focus on cases in the United States.    Studies of fentanyl-related overdoses show that victims are typically female, white non-hispanic, and older than the usual overdose demographic.   Even the Actiq lollipops are becoming increasingly available on the black market (where they are commonly known as "percopops").   Though most prescription pain medications have become popular as street drugs, fentanyl is rapidly becoming a drug of choice given its extreme potency.  Some dealers are even mixing it with heroin which has led to a rash of overdose deaths across the United States (and elsewhere).   Much of the fentanyl sold on the black market comes from Mexico but black market labs manufacturing fentanyl and counterfeit oxycontin tablets have also been found in the United States and Canada.   The high potency and extended duration of some fentanyl compounds make its manufacture extremely profitable for street use. 

Despite controversy over prescribing long-term opioid medications for chronic non-cancer pain, the increasing popularity of these medications has made their availability as street drugs a fact of life.  National surveys of drug use have shown that nearly 12 million Americans 12 years old or over (4.8% of the population), have reported non-medical use of prescription pain relievers.   ER visits relating to non-medical opioid use have skyrocketed over the past decade and the death rate due to overdose is at an all-time high. While most of those deaths have been linked to more popular opioid pain relievers such as oxycodone (i.e., Oxycontin or Percocet) and hydrocodone combinations (i.e., Vicodin), fentanyl deaths are becoming increasingly more common.    As high-profile cases involving accidental fentanyl deaths have demonstrated, that trend is likely to continue. 

 

 

Dealing With Concentration Camp Syndrome

The celebration that greeted the end of World War II in 1945 was naturally tempered by sadness over the millions of lives that had been lost.  Along with mourning the war dead, people around the world also acknowledged the tremendous problems that needed to be faced in reconstrucion.  Along with the economic hardships that recovering nations had to cope with, dealing with the prisoners who had been liberated from German and Japanese concentration camps posed unique problems as well.    While the logistics of caring for Allied soldiers and civilians who had been prisoners of war was daunting enough, there were also the members of the various persecuted minorities that had faced the Holocaust, many of whom had lost their entire families as well as surviving nightmarish treatment in the death camps. 

As former prisoners of war returned home, medical professionals became aware of specific signs of physical and mental disease resulting from their ordeals.  While "combat psychosis" (an earlier version of posttraumatic stress disorder) had become recognized in the clinical literature (grudgingly), what the returning soldiers were displaying seemed disturbingly different.    These various problems that they displayed included: premature aging, visual impairments, extreme weight loss, abnormal liver functioning, bronchitis, emphysema, and tuberculosis.  Many also had evidence of severe physical trauma including fractures, internal bleeding, and contusions.  In addition to these medical issues, females who were former prisoners of war also experienced suppresed menstruation.   Along with the physical symptoms,  there were also a disturbing array of psychiatric symptoms as well   Many former prisoners complained of chronic depression, sleep problems, nightmares, loss of pleasure, irritability, and exaggerated startle reactions.  Problems with memory and concentration were present as well as psychosomatic symptoms such as anorexia, panic disorder, and autonomic symptoms of anxiety (rapid heartrate,  sweating, and palpitations).  The combination of symptoms in former prisoners became common enough to be identified in the clinical literature under a variety of names including "concentration camp syndrome", "concentration camp survivor syndrome", "repatriation neurosis", or KZ syndrome (short for the German term Konzentrationslager).  

Although the establishment of the Geneva Convention was meant to ensure the human treatment of prisoners of war during wartime, the 20th century has seen a range of brutal conflicts with continuing breaches of international law.  Research examining former prisoners of war and concentration camp survivors has yielded interesting variations in long-term adjustment following release.   American soldiers who had been prisoners of war in German internment camps showed relatively few psychological problems since the Nazis tended to comply with the Geneva Convention for Allied prisoners (albeit under pressure from international aid groups).  Soldiers interned in Japanese camps, however, were a different story.  Since Japanese military tradition regarded soldiers who allowed themselves to be taken prisoner with contempt, Allied prisoners of war often faced severe abuse (including being subjected to horrendous medical experiments at times).    Death rates were as high as 50% in some compounds in Southeast Asia and in the Pacific.   Clinical researchers examining survivors of Japanese camps found mortality rates, including  deaths from tuberculosis, cardiovascular disease, cancer and suicide, to be far higher rate than comparison subjects of equivalent age who had not been prisoners.  Similar findings were obtained by researchers examining soldiers who had been prisoners in North Korean camps during the Korean war.   For former prisoners,  violent accidents, suicide. and murder accounted for more than 50% of total mortality.

Reentry into society has been characteristically difficult for returning prisoners, especially those who had been interned in Japanese and Korean camps since medical professionals were poorly equipped to deal with KZ syndrome (which was still relatively unknown).   In addition to severe disorientation relating to attempt reintegration into peacetime, returning soldiers showed high rates of unemployment and failure to adapt to work environments with severe impairments in vocational and social adjustment.  Children of former inmates also reported emotional problems stemming from dealing with one or both parents suffering from KZ syndrome and clinical research into intergenerational transmission of trauma has demonstrated the long-term persistence that such trauma can have.   While KZ syndrome has often been linked to posttraumatic stress disorder, especially in terms of proneness to flashbacks, irritability, and exaggerated startle reactions. former prisoners also displayed additional symptoms including pervasive depression and survivor guilt.  

During the course of the long Vietnam war, returning prisoners of war became a more common phenomenon.  The range of presenting symptoms that former prisoners displayed often varied according to where in Vietnam they had been held captive.   Prisoners who had been held by the Vietcong in the North tended to be less harshly treated and had a lower mortality rate than those who had been held in the South.   While it was standard practice for all returning prisoners to have a complete medical and psychosocial examination upon their return to the United States, prisoners from North Vietnam seemed relatively fit and healthy regardless of the length of their captivity.  Prisoners from South Vietnam, however, often had severe physical and psychological disabilities which tended to persist long after their release.   Factors that appeared to play a role in surviving imprisonment included a strong motivation to live, well-controlled or balanced sensitivity, sense of humour, assertiveness, and an action-oriented coping style.   Being able to deal with solitary confinement represents a critical coping strategy, whether through communicating with other captives, physical activity, mental exercises, or the planning of escapes.   It also helped that the North Vietnamese were more likely to regard their prisoners as potentially valuable which made them less likely to engage in torture or systematic extermination.   It was the need to provide better mental health care for hundreds of thousands of returning Vietnam veterans (many of whom had been prisoners of war) that led to political pressure from veterans groups for the addition of posttraumatic stress disorder to the Diagnostic and Statistical Manual of Mental Disorders.  The diagnosis was formally adopted in 1980 and thousands of U.S. veterans continue to receive disability benefits for PTSD-related conditions.

Survivors of the Holocaust also displayed a characteristic set of psychiatric problems which were often linked to the horrors they faced in the camps.  There have been thousands of research studies outlining the psychological consequences of their internment and later reintegration into post-war society.   Survivors reporting on their experiences in the camps tended to identify lingering issues stemming from the constant fear of their lives that they experienced, as well as physical trauma resulting from beatings, hunger, and forced labour.  These stressors tended to poison all interpersonal contacts and relations.  Survivor guilt was an additional factor given that most prisoners lost family members and friends leaving them with the feeling that they had been wrongly spared while more worthy victims died.  Since many prisoners often engaged in whatever acts they deemed necessary for survival (including stealing food or cooperating with their captors), an additional burden of guilt was often added.  Along with harsh treatment, prisoners were typically subjected to severe indoctrination designed to justify the genocidal policies and reinforce the idea that they deserved to die.  That survivors were left with deep psychological scarring wasn't surprising.  Some Israeli researchers later reported an extremely high incidence of psychiatric disorders among survivors which typically persisted for decades in many cases.   Ironically,  inmates with preexisting psychiatric problems were typically the first to be killed (in keeping with Nazi eugenic policies relating to mental illness).  

What seemed more surprising for clinicians dealing with Holocaust survivors was the resilience that many survivors showed in dealing with their ordeal.  Despite early pessimism  concerning eventual recovery,  long-term studies of Holocaust survivors have shown evidence of good adaptation in dealing with posttraumatic symptoms.  In addition to provided powerful testimony concerning their experiences, survivors such as Viktor Frankl and Elie Wiesel have inspired generations of readers with their writing.   The resilience shown by Holocaust survivors does not immunize them from later health problems, however.  While specialized treatment programs (especially in Israel) have helped Holocaust survivors to lead relatively normal lives, their vulnerability to later stress situations, such as hospitalization and diseases of old age, remains the focus of clinical research. 

Given the frequent examples of genocide that have been perpetrated since 1945, whether in Cambodia, the former Yugoslavia, Somalia, Sudan, Rwanda, or numerous other places, as well as dealing with former hostages who have survived long-term captivity, the lessons learned from prisoners or war and Holocaust survivors seem more relevant than ever.    Providing psychological counseling for refugees scarred by their own experiences with torture and imprisonment remains a challenge that mental health professionals are often ill-equipped to address.  The only real certainty is that, as new conflicts arise, we will continue to see an overwhelming number of refugees needing help to reenter society.

 

 

 

 

 

 

 

 

 

Learning from Katrina and Other Disasters

A recent article in Psychological Trauma: Theory, Research, Practice, and Policy presents a review of the book, Crisis and disaster counseling: Lessons learned from Hurricane Katrina and other disasters edited by Priscilla Dass-Brailsford. This book is an excellent text for clinicians who respond to and work with clients in crises resulting from disasters. The book consists of 15 chapters covering distinct, yet related, topics. Whereas some chapters deal exclusively with Hurricane Katrina, others have a broader focus, offering insight that will be helpful in responding to any crisis. Geared toward clinicians, the text is written in clear, easily comprehended, concise prose. Each chapter is structured in a similar fashion and contains chapter highlights as well as practical implications presented in bullet points for easy review. Readers of this book treating trauma and traumatic grief in children and adolescents will not be disappointed. The seasoned crisis worker will benefit from the unique information gained from those who responded to Hurricane Katrina, both immediately and long after the destruction. The novice clinician will begin to gain an understanding of the complexity of working with those in crisis and the challenges and implications of such work that need to be considered.

For the abstract.

p.s.  On a related noted, I recently published a post on New Orleans' efforts to recover from Hurricane Katrina and Rita.  You can read it here.  

Do Popular Anti-Smoking Medications Increase Suicide Risk?

Although tobacco use is responsible for one in five deaths in the United States each year and adds more than $193 billion to health care costs, it remains one of the most treatment-resistant forms of substance abuse known.  Considering  the difficulties that smokers face in quitting "cold turkey", physicians often prescribe a variety of nicotine replacement products to help their patients end their smoking habit.  These products include transdermal patches that release nicotine into the skin as well as antidepressant such as buproprion (marketed as Wellbutrin or Zyban) and varenicline (marketed as Chantix in the United States and Champix in other countries).    

While nicotine withdrawal has been known to cause a variety of psychological symptoms including irritability, insomnia and weight gain, depression and suicidal thinking is not commonly found in patients trying to quit smoking.   Unfortunately, incidents of suicide in patients who have been prescribed buproprion and varenicline have led the Food and Drug Administration to issue Boxed Warnings to physicians prescribing these medications to patients who smoke.  Patients prescribed these medications are also issued a mandatory Medication Guide warning of possible psychiatric effects including suicidal behaviours and depression. 

But do these popular smoking cessation products increase suicide risk?  In a recent study published in the Public Library of Science journal PLoS One, a team of researchers compared clinical case reports examining health risks in using varenicline and buproprion for smoking cessation.  Led by Thomas J. Moore of the Institute for Safe Medication Practices and Curt D. Furberg of the Division of Public Healh Sciences, Wake Forest University, the researchers examined FDA case reports from 1998 through September 2010 using the FDA's Adverse Event Reporting System.  All of the case reports were based in the United States and involved a serious medical outcome (i.e., death or hospitalization).  As a comparison group, they researchers also included case reports for other nicotine replacement products and combined case reports for several commonly used antibiotics.    All case reports were examined for incidents of suicidal or self-harm behaviour and possible interactions with other medications being taken at the same time were also considered.   A total of 17,290 case reports were examined including 13,243 cases in the smoking cessation group and 4,047 in the antibiotic comparison group.   In the smoking cessation group, 3,249 cases (25% of the total) showed evidence of suicide attempts or self-harm behaviour compared to only 48 cases in the antibiotic group (1 % of the total).   Although some differences were found between smoking cessation and antibiotic populations (antibiotics users had a wider age range for example),  the overall demographics were similar across all the compared groups.

Of the smoking cessation medications specifically examined by the researchers, varenicline showed the greatest risk although buproprion showed an elevated risk for suicidal behaviour as well.  There was no difference between risk for suicide attempts or self-harm behaviour when examined separately.  Compared to the antibiotic group, risk of suicidal behaviour was elevated for all three smoking cessation groups although non-prescription nicotine replacement treatment showed the lowest suicide risk.    Related symptoms, including headaches and pain, were also higher in the smoking cessation groups compared to the antibiotic group although this may be related to nicotine withdrawal.  Overall, varenicline showed the highest suicide risk despite it being a relatively new product (varenicline was only available to patients for four years during the thirteen-year period that the study examined).   Of the 3,249 cases of suicidal behaviour  specifically linked to smoking cessation products,  2,925 (90 %) involved varenicline.   Only 229 cases (7%) involved buproprion and 95 (3%) involved nicotine replacement therapy.   For completed suicides, 272 of the 295 cases examined involved varenicline.   

In examining these results, the researchers concluded that varenicline showed a markedly higher overall risk compared to all other smoking cessation products.  While buproprion shows an elevated risk as well, the authors warn that varenicline, under its brand name of Chantix, should not be prescribed for first-line use in helping patients quit smoking.     While mandatory health warnings are included by Pfizer in its advertising for Chantix, patients hoping to quit smoking are advised to warn their doctors and the FDA of any suicidal thoughts that develop after taking the medication. 

 

The Boltzmann Mystery (Part 2)

Continued from Part 1

In 1889, his oldest son, Ludwig, died of  undiagnosed appendicitis.  Along with the guilt that he felt for failing to recognize how serious his son's illness was, Ludwig Boltzmann also became increasingly isolated and insecure in his own department despite being one of the world's most eminent physicists.  When a colleague secured a position for him at the University of Munich, Boltzmann gratefully accepted (although he was careful not to burn any bridges behind him when he left Austria).  While he enjoyed his new work in Munich, the lack of any formal pension left him increasingly worried about what would happen to his family if he became disabled.  This was a special concern for him due to his deteriorating eyesight.  Although his wife regularly read scientific papers to him to spare his eyes, Boltzmann was terrified by the prospect of going blind completely.    He also became homesick for Austria and eventually accepted a position at the University of Vienna in 1894 after years of waffling (the decidng factor was the prospect of complete pension in case he became disabled).

Despite international recognition (including an honorary degree from Oxford where he was revered), Boltzmann felt increasingly isolated in his native country.  He travelled frequently and gave guest lectures across Europe and North America but was prone to intermittent episodes of depression.  His frequent scientific arguments with other physicists (especially Ernst Mach) left him exhausted and he soon found himself in a new position at the University of Liepzig in 1900.   It was shortly after arriving in Liepzig that he made his first suicide attempt and he officially retired a year later due to a stroke.  While he was able to return to Vienna in 1902, the rumours concerning his mental health made the university uncomfortable and Boltzmann had to make a promise in writing that he would not attempt to leave Austria again. 

By then, Ludwig Boltzmann's health problems severely impaired his ability to function as a lecturer.  In addition to severe asthma attacks and poor eyesight (he hired an assistant to read all of his course material to him), he also experienced bad headaches and what appears to be angina episodes as well.   These health issues didn't stop him from frequently working until early in the morning and travelling abroad giving lectures.  His last lecture  tour of the United States was in 1905 and the problems that Boltzmann was experiencing were readily apparent to his American colleagues.  Not only was he plagued by repeated asthma attacks but his hosts at Berkeley were somewhat disgruntled by the odd manic behaviour that he was displaying.  Still, he gave more than thirty lectures and newspaper reporters described his American tour as a triumphant success.  Boltzmann was not so enthusiastic and he was openly disappointed that his lecture tour was not as successful as previous ones had been.

Shortly after returning from California, Ludwig Boltzmann committed suicide.  Although he was known to suffer from depression, his jovial description of his trip to California seemed enough to reassure friends and family that things were under control.   Since he left no suicide note, his exact reason for killing himself remains unknown.  Life managed to go on for Boltzmann's family and colleagues.  Although lectures in theoretical physics at his university were suspended for eighteen months after the suicide, Boltzmann's position was eventually filled by Friedrich Hasenohrl who dedicated his inaugural lecture to Ludwig Boltzmann and his research.  Erwin Schrodinger and Ludwig Wittgenstein were particularly devastated by the great physicist's death since they had both been hoping to study with him.  As for Henriette Boltzmann, she outlived her husband by more than thirty years before finally dying in 1938.   Of all the Boltzmann children, it was Elsa, the daughter who discovered the body, who lived with the memory of her father's suicide the longest.   Until her death in 1966, she steadfastly refused to talk about her reaction at finding her father's body. 

While the usual caution about attempting to diagnose historical figures based solely on available accounts certainly applies here, the question of the exact nature of the psychiatric problem that Ludwig Boltzmann experienced still remains.   In addition to the "neurasthenia" diagnosis he received during one of his repeated hospitalizations (a catch-all psychiatric label that was popular at the time), several biographers have speculated on the possibility that he suffered from bipolar disorder, primarily due to the apparent mood swings that he demonstrated at times.  He often showed manic enthusiasm for his research work which could abruptly shift to deep depression.  Even Boltzmann observed these mood swings and  joked that they were due to his being born on the night between Mardi Gras and Ash Wednesday.   If he were diagnosed today, he would likely be considered to be suffering from late-onset bipolar disorder given that he was almost fifty when the first symptoms developed.   The lack of any close relatives with psychiatric problems also reflect the possible late-onset diagnosis although, again, we will likely never know for certain.  While never formally diagnosed, Ludwig Boltzmann is often listed among famous bipolar individuals.    Whatever the diagnosis, Ludwig Boltzmann's life provides a fascinating example of the surprising ways in which scientific genius and mental illness can interact.  Whether modern medical treatment would have enabled him to function longer is another question that can never be answered.

As a final postscript to Ludwig Boltzmann's saga,  a commemorative plaque in his memory was mounted at the Hotel Ples on September 4, 2006 near the site where he committed suicide.  It represents a sobering reminder of the death that rocked the scientific world so long ago. 

 

 

How Common is Suicide in the U.S. Military?

 How common is suicide in the U.S. military?  While previous research has actually shown that suicides occurred less frequently in the different branches of the U.S. military as compared to the general population, suicide prevention programs developed in the 1990s have helped lower suicide rates among active-duty members over the past twenty years.   In recent years, however, high-profile cases of suicides in  veterans returning from tours of duty in Iraq, Afghanistan, and other high-risk deployments have shown a disturbing reversal of this long-term trend.  According to a 2007 report by the Department of Defense Task Force on Mental Health, possible reasons for higher incidence of suicide in returning veterans include lack of proper treatment resources, greater stress resulting from prolonged deployments overseas with a high risk of death and/or disability, and failure to acknowledge the potentially crippling effects of post-traumatic stress disorder.   Considering the stigma often associated with mental illness, especially in a military culture that tends to regard emotional problems as a sign of weakness, service members are often reluctant to seek help for suicidal thoughts until it is too late.   While military training is designed to toughen soldiers to the harsh realities of overseas deployment, it can also make treatment for suicidal thinking more difficult.  Overseas deployments also serve to isolate service members from their natural support networks, i.e., family, friends, and the extended community to which they belong which may make them increasingly vulnerable to suicidal thoughts.

In a comprehensive research study recently published in the Journal of Consulting and Clinical Psychology,  a team of researchers examined suicidal behaviour in active-duty members of the United States Air Force.  Led by Dr. Jennifer Langhinrichsen-Rohling of the University of South Alabama and a group of clinicians from Stony Brook University, the study took information from the 2006 Air Force Community Assessment.    Administered every two years, the Air Force Community Assessment is an anonymous survey administered to Air Force serving members at 82 Air Force bases worldwide.  Designed to provide support agencies with information on individual, family, workplace, and community problems as well as sensitive information on mental health issues, including suicidal thinking.    The survey is given online on a purely voluntary basis.   A total of 52,780 active-duty Air Force members completed the survey (79.3% male, 20.7% female) with an average age of 31.78 years.  According to the study results, the one-year rate for suicidal ideation (i.e., recurrent thoughts about/or seriously considering suicide) was four per cent for the total group.   Factors potentially contributing to suicidal ideation included problems on the individual level such as alcohol problems and depression.  Relationship issues including intimate partner violence and marital dissatisfaction, workplace problems, i.e., job dissatisfaction and hours worked, and lack of socal support were also found to be possible factors in suicide.  The authors conclude that military suicide prevention efforts need to focus on multiple levels including individual, family, workplace, and community problems that might contribute to increased suicide risk.  They also acknowledge that their findings were based on self-report information alone and that suicide completers in the military are often less likely to seek help than suicide attempters.  For that reason, military suicide programs also need to focus on the role that stigma can play in preventing actively-service military members from seeking help until it's too late.

For the abstract

 

 

How Do Prisons Deal With An Aging Population?

In an ombudsman's report which he tabled this week, Correctional Investigator for Canada, Howard Sapers, has warned that Canada's federal prison system is ill-equipped to deal with prisoners who are developing a range of medical problems associated with aging.    Despite a new $2 billion federal initiative to expand existing prison facilities by 2700 beds and replacing antiquated prisons,  tougher sentencing and more rigid criteria for granting parole and probation will likely aggravage existing crowded prison conditions, especially in the short-term.

Prison inmates with mental health and chronic medical conditions  already face lengthy waiting lists to receive often-inadequate treatment programming.   The average age for prison inmates has risen sharply in the past decade with one in five being over the age of 50.   As more prisoners enter the prison system at a later age, they are often ill-suited to deal with prison life which makes them extremely vulnerable to harassment and extortion by younger inmates.  Since older inmates are often prescribed medication to deal with medical conditions, they are frequently "muscled" for their medications which younger inmates then sell or use for their own benefit. 

In preparing his report, Mr. Sapers met with aging inmates from institutions across Canada.   Many of these offenders report regular muscling which they are rarely inclined to report to prison staff for fear of reprisal.   The existing problems are expected to worsen as inmates become increasingly prone to physical and cognitive impairments linked to age-related diseases.   While cases of Alzheimer's Disease and other forms of dementia are still relatively rare, that is likely to change in the coming decades.  Korsakoff's Syndrome, which is often associated with chronic alcoholism, will probably become more common in prison populations as well.  Given the limited facilities to accomodate inmates with severe psychiatric and medical problems, these inmates are often housed in segregation cells which aggravates their symptoms.

In his new report, Mr. Sapers is calling on the Correctional Service of Canada to upgrade existing facilities to accomodate special medical needs, including wheelchair ramps, accessible bathrooms, and wider aisles.   He is also recommending the hiring of more staff with training in palliative care and geriatrics.  Sensitivity training to address a wide range of aging issues is also needed as well as the development of age-appropriate recreation and exercise programs.  Mr. Sapers also suggests that specialized geriatric units may also be necessary as the number of elderly inmates rises. 

In responding to the Sapers report, Dr. Stanley Yaren, past president of the Canadian Psychiatric Association, stated that "Prisons were never designed to be treatment facilities.  They are not therapeutic settings and are not resourced to provide mental health services to such a profoundly ill population."   With the inevitability of age-related medical problems as prisoners grow older, that will likely need to change.

For more information

 Correctional Investigator's 2010-2011 report (PDF)