Atlanta mass shooter's family blames his actions on psychiatrists' refusal to rx benzos.

[PsyDr]

Police arrest suspect in Atlanta shooting; 1 dead, 4 wounded

Police say they are investigating an “active shooter situation” in a building in Atlanta’s Midtown neighborhood and that multiple people had been injured. The Atlanta Police Department said on Twitter that the active shooter was inside a building on West Peachtree Street, between 12th and 13th...

apnews.com

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[comp1]

I can't judge the mom. Her trauma is immense and she's just grasping trying to understand. I just really wish the news would maybe not focus on this...

 

[Candidate2017]

His nurse mom is correct. If you put enough Ativan into someone's system, they'll be sleeping rather than shooting.

 

[docksan]

I get where she's coming from, but saying "I'm a nurse they should have done this" really misses the mark by miles and tracks well.

 

[birchswing]

<Not a doctor or medical student>

Reading between the lines, he was on the Ativan, then off of it and some other med put in place as a replacement (the one referenced as started on Friday), and he wanted to go back on the Ativan?

That's just parsing the very limited data in the article.

The VA guidelines are incredibly rapid with regard to benzo withdrawal compared to the NICE guidelines, for example, and specifically don't mention patient autonomy which the Ashton Manual on which the NICE guidelines were largely based mention as paramount. I don't think you could rule out homicide/suicide as an effect of withdrawal. People can go into frank psychosis from withdrawal. I recently came across safetaper.com —california based outfit for de-prescribing in a more informed way based on a modified Ashton approach. I was not impressed with the VA's guidelines when I read them.

And I can't count the number of times I've seen medical authorities write that all manner of psychiatric drugs like SSRIs can be used for the "rebound anxiety" which in my opinion isn't rebound anxiety at all—rebound anxiety would be nothing compared to benzo withdrawal, and I don't even know how anyone can claim to see it in a distinguishable state in the fog of withdrawal symptoms.

My gut instinct is to blame the pendulum swings with policing of drugs. I would bet dollars to donuts he had been on them for a prolonged period and taken off, that this was not a benzo-naive demand. I could be wrong—there's that odd detail about the truck running waiting, which seems very deliberate. But the way the mother referred to it as "his Ativan" makes me think he had been on it for some time.

 

[Fan_of_Meehl]

<Not a doctor or medical student>

Reading between the lines, he was on the Ativan, then off of it and some other med put in place as a replacement (the one referenced as started on Friday), and he wanted to go back on the Ativan?

That's just parsing the very limited data in the article.

The VA guidelines are incredibly rapid with regard to benzo withdrawal compared to the NICE guidelines, for example, and specifically don't mention patient autonomy which the Ashton Manual on which the NICE guidelines were largely based mention as paramount. I don't think you could rule out homicide/suicide as an effect of withdrawal. People can go into frank psychosis from withdrawal. I recently came across safetaper.com —california based outfit for de-prescribing in a more informed way based on a modified Ashton approach. I was not impressed with the VA's guidelines when I read them.

And I can't count the number of times I've seen medical authorities write that all manner of psychiatric drugs like SSRIs can be used for the "rebound anxiety" which in my opinion isn't rebound anxiety at all—rebound anxiety would be nothing compared to benzo withdrawal, and I don't even know how anyone can claim to see it in a distinguishable state in the fog of withdrawal symptoms.

My gut instinct is to blame the pendulum swings with policing of drugs. I would bet dollars to donuts he had been on them for a prolonged period and taken off, that this was not a benzo-naive demand. I could be wrong—there's that odd detail about the truck running waiting, which seems very deliberate. But the way the mother referred to it as "his Ativan" makes me think he had been on it for some time.

Article is (of course) short on any real relevant medical/historical/clinical details and they matter...a lot. None of us know those details but I'm sure there will be about 5,000 'root cause analyses' conducted.

1000% agreed that benzo withdrawal/tapering is generally poorly handled at VA and needs to improve (if that was, indeed, the case in this instance). It's entirely possible that the clinical care was substandard prior to and during the most recent visit, who knows.

But I'd also say that there is a real problem with the culture at the VA (and this generally extends to the lay public, news media, politicians, etc.) to be so quick to adopt a blaming attitude towards institutions and/or clinicians who make clinically appropriate decisions if those decisions are not what the veteran patient 'wants' or says he/she 'needs.' Sometimes boundaries have to be enforced and--all too often--permissive 'whatever you want, you get' philosophies abound and then the enabled patient encounters someone who enforces appropriate boundaries and/or delivers appropriate diagnoses/care and all hell breaks loose in the form of a sudden 'extinction burst' of intimidating and violent behaviors after a learning history of constant reinforcement of same. In the context of additional disinhibition due to intoxication or some other factor, tragedy can happen. At our VA today, they sent out a mass email reminding everyone of the Federal law that prohibits anyone (other than police) from carrying firearms into VA hospitals because...you know...if someone had just thought to send an email like that a couple days ago it would have prevented all this tragedy (/sarcasm). Sorry, just had one of those weeks providing care at VA and it's Friday (thank God).

 

[docksan]

While I agree that withdrawal is too easily precipitated at the VA, Ativan without context is almost never universally prescribed for anxiety there. It's probably more likely the veteran came in on it and it was continued, or they were prescribed it for withdrawal management (alcohol), OR were seen by a non psychiatrist who started it because they're not a psychiatrist and don't know better. It could also be it was stopped because he violated protocol and it couldn't be continued. It's very clear he was dependent.

But withdrawal resulting in homicidal or suicidal behavior, even psychosis? Not on the regular, and if the psychiatrist thought that and didn't address it then that's a very, very bad doctor because there are several layers of protocol that prohibit you from not addressing high risk patients when they're in crisis.

I'm more inclined to believe the fault lies with the mother for not fully understanding the situation, but could consider the system failed since it does happen.

 

[PikminOC]

While I agree that withdrawal is too easily precipitated at the VA, Ativan without context is almost never universally prescribed for anxiety there. It's probably more likely the veteran came in on it and it was continued, or they were prescribed it for withdrawal management (alcohol), OR were seen by a non psychiatrist who started it because they're not a psychiatrist and don't know better. It could also be it was stopped because he violated protocol and it couldn't be continued. It's very clear he was dependent.

But withdrawal resulting in homicidal or suicidal behavior, even psychosis? Not on the regular, and if the psychiatrist thought that and didn't address it then that's a very, very bad doctor because there are several layers of protocol that prohibit you from not addressing high risk patients when they're in crisis.

I'm more inclined to believe the fault lies with the mother for not fully understanding the situation, but could consider the system failed since it does happen.

Didn't he then also go and shoot his boss at McDonald's too? Before he was caught

 

[docksan]

Right. Can't tell you how many times I've had family members not understand the dangers was we understand them and, despite explaining it multiple times, still insist the doctors did it to their loved one.

Mistakes can and do happen at the VA, but man this kind of situation is one that rarely happens because of how tightly regulated controlled substances are with psychiatry.

The fact that his mother wouldn't say what the alternative drug was is still understandable in some ways, but goes a long way in demonstrating the vast difference in knowledge and practice between fields. A great nurse is amazing to work with, but that doesn't mean his mother knows best.

 

[JKinSC]

Didn't he then also go and shoot his boss at McDonald's too? Before he was caught

I can only assume that's because the ice cream machine was broke

 

[allantois]

Charge the mother ffs

 

[G Sheb]

The VA is a tough place to work.
Very high risk patients, with hx of addiction, trauma and sometimes a psychotic or a mood illness on top.
Sometimes it's not the fault of anyone. Ativan is likely not the right medication, and a high risk patient with hx of violence will sometimes act in a fit of rage.
What is inarguable is that a volatile patient should not have access to guns.

 

[annoyedpsychiatrist]

<Not a doctor or medical student>

Reading between the lines, he was on the Ativan, then off of it and some other med put in place as a replacement (the one referenced as started on Friday), and he wanted to go back on the Ativan?

That's just parsing the very limited data in the article.

The VA guidelines are incredibly rapid with regard to benzo withdrawal compared to the NICE guidelines, for example, and specifically don't mention patient autonomy which the Ashton Manual on which the NICE guidelines were largely based mention as paramount. I don't think you could rule out homicide/suicide as an effect of withdrawal. People can go into frank psychosis from withdrawal. I recently came across safetaper.com —california based outfit for de-prescribing in a more informed way based on a modified Ashton approach. I was not impressed with the VA's guidelines when I read them.

And I can't count the number of times I've seen medical authorities write that all manner of psychiatric drugs like SSRIs can be used for the "rebound anxiety" which in my opinion isn't rebound anxiety at all—rebound anxiety would be nothing compared to benzo withdrawal, and I don't even know how anyone can claim to see it in a distinguishable state in the fog of withdrawal symptoms.

My gut instinct is to blame the pendulum swings with policing of drugs. I would bet dollars to donuts he had been on them for a prolonged period and taken off, that this was not a benzo-naive demand. I could be wrong—there's that odd detail about the truck running waiting, which seems very deliberate. But the way the mother referred to it as "his Ativan" makes me think he had been on it for some time.

I taper people off benzos all the time. The VA protocol I would hardly call rapid, if anything its quite fair and works well for low-moderately dosed benzos. In higher dosed benzos, I would still argue that it does what its intended to do, if you go in with the mindset of some people may require a little extra time on higher doses. Either way, its much easier to go down initially from a higher dose, the middle and the end can often be the hardest parts. They use three months, with one month of holding and for people on low to moderate dosing I dont think this is bad at all. People on higher doses may take a bit longer.

There are quite frankly two types of people on chronic long term benzos. Personality disorder patients who are misusing them, and people who were improperly prescribed them by a stupid doctor who practices conveyor belt medicine (though im not calling out doctors who are giving patients .25mg of xanax or something of that nature, as that can be situational).

Respecting autonomy and giving the patient a voice works great for the second group of patients. I do this routinely. I combine CBT with this and I work hard on deconstructing their anxiety, putting into perspective, and forcing them to expose themselves to situations. I had a patient who came to me on 30mg valium, severe social phobia. I saw him monthly, we did CBT and gradual reduction, hes currently on 5mg daily valium, his anxiety is BETTER, and he messaged me last week to inform he was promoted to a supervisor role in his job and now leads presentations in his office, which he previously was terrified of. He had many great personality traits, but he lacked any kind of confidence in himself, and the benzos helped him to avoid confronting that self doubt and I was able to make him see they hurting him, not helping him. I have another girl who was on 6mg klonopin, I have her down to .5mg BID. She was surprised to see that her anxiety wasnt any worse on the lower dose. She wanted to get better. You see, respecting autonomy and patient's opinions works great for this group of people because deep down they want to get better. I believe CBT/therapeutic alliance>>>any alternative medication when tapering off benzos.

The other group of people are not ready to get better. They want medications to give them a sedation vacation. The ashton method is garbage for these people. If I give them valium on top of their xanax then they're going to end up on the side of the road completely snowed. I unfortunately get a lot of these people referred to me and the reality is shared decision making does not work with them because they don't actually want to go off the medication at their core.

The NICE guidelines I am undecided on. They say convert everyone to valium basically. The thing is, some people do worse switching to valium instead of just gradual reduction of their current benzo. I think people always assume switching to valium makes the withdrawl better in every way, but part of the withdrawl is psychological so switching to a completely different benzo can be scary to a lot of people. And some people just seem to tolerate that worse. For high risk patients I could see how this protocol would make sense, but patients on low to moderate dosing of things like ativan and klonopin, I usually just do gradual dose reduction of their current medication.

I can say this though- ive seen people improperly tapered off benzos, but have yet to see them shoot people as a result. Thats not due to anxiety or ativan, lets not give this situation any excuses, because its a miracle he didnt kill the doctor as well. If anything, it just shows healthcare workers need more protection, not that patients need more rights. The customer is not always right in psychiatry, and if he was being taken off ativan then there may have been a reason why. If hes using too much, and frankly youre past the point of being able to taper him successfully because hes just generally not compliant, then you dont have a lot of options.

 

[Fan_of_Meehl]

I can say this though- ive seen people improperly tapered off benzos, but have yet to see them shoot people as a result. Thats not due to anxiety or ativan, lets not give this situation any excuses, because its a miracle he didnt kill the doctor as well. If anything, it just shows healthcare workers need more protection, not that patients need more rights. The customer is not always right in psychiatry, and if he was being taken off ativan then there may have been a reason why. If hes using too much, and frankly youre past the point of being able to taper him successfully because hes just generally not compliant, then you dont have a lot of options.

THIS...times a bajillion.

If my encounters with psychopathology (especially of the Axis II type) across my lifetime have taught me anything it is the Iron Rule of Crazy which is...

'inappropriate boundary pushing will continue and will escalate until effective resistance is encountered and/or reinforcement is withdrawn'

 

[birchswing]

The VA is a tough place to work.
Very high risk patients, with hx of addiction, trauma and sometimes a psychotic or a mood illness on top.
Sometimes it's not the fault of anyone. Ativan is likely not the right medication, and a high risk patient with hx of violence will sometimes act in a fit of rage.
What is inarguable is that a volatile patient should not have access to guns.

There needs to be more consensus on guns. Progressives, which is the side I'm on, often talk about the number of guns, which ignores the fact that Switzerland has a very high gun ownership rate and isn't plagued with the violence of the US. But of course Switzerland does not have all of the economic despair so many face in the US which I think is directly related to mental health if not mental illness. And economic despair is not something you hear conservatives talk about a lot. They do trot out mental health help when they are mass shootings, and I don't know what that means in tangible terms, but I say if it's sensical it should be taken up. I think Mike Pence even brought out the ideas of asylums, and if they're serious about that, I don't see what would be bad about modern, humanistic asylums. That seems very progressive. But I also think you have to take economic despair into account.

Without change to mental health, to culture, to economic justice, I think a case can be made that the US collectively is not capable of having the latitude of gun ownership permissiveness that it does, which goes back to the liberal cause of gun control through limiting the types of guns on the market. Maybe we just aren't responsible enough collectively, and yet it can at the same time be true that a country like Switzerland is. Conservatives can be hypocritical of this in their support of stop-and-frisk, which is nothing if not gun control. I don't know enough to comment on the abuses of that system or the racial profiling, but it does speak to the fact that crime in the US that in other countries would be petty crime often involves guns escalating the nature of the crime in the US, for cultural reasons I don't entirely understand. I guess it's a self-fulfilling arms spiral. But why is a policy like stop-and-frisk in urban areas tolerable to conservatives but not limiting the type of weapons people own?

Article is (of course) short on any real relevant medical/historical/clinical details and they matter...a lot. None of us know those details but I'm sure there will be about 5,000 'root cause analyses' conducted.

1000% agreed that benzo withdrawal/tapering is generally poorly handled at VA and needs to improve (if that was, indeed, the case in this instance). It's entirely possible that the clinical care was substandard prior to and during the most recent visit, who knows.

But I'd also say that there is a real problem with the culture at the VA (and this generally extends to the lay public, news media, politicians, etc.) to be so quick to adopt a blaming attitude towards institutions and/or clinicians who make clinically appropriate decisions if those decisions are not what the veteran patient 'wants' or says he/she 'needs.' Sometimes boundaries have to be enforced and--all too often--permissive 'whatever you want, you get' philosophies abound and then the enabled patient encounters someone who enforces appropriate boundaries and/or delivers appropriate diagnoses/care and all hell breaks loose in the form of a sudden 'extinction burst' of intimidating and violent behaviors after a learning history of constant reinforcement of same. In the context of additional disinhibition due to intoxication or some other factor, tragedy can happen. At our VA today, they sent out a mass email reminding everyone of the Federal law that prohibits anyone (other than police) from carrying firearms into VA hospitals because...you know...if someone had just thought to send an email like that a couple days ago it would have prevented all this tragedy (/sarcasm). Sorry, just had one of those weeks providing care at VA and it's Friday (thank God).

But how many benzo naive people come to psychiatrists begging for benzos? When you say no, is it ever to someone who has never been on a benzo before? Or is it someone who was put on a benzo and is now sick because of it?

WIth opioids there's always the debate about whether it's more iatrogenic versus recreationally induced. I don't see how that debate can be had with benzos. If someone wants to just intoxicate themselves, alcohol flows freely.

If you look at reddit's recreational benzo forum, the very top pinned post is a video of a person in the thralls of cold-turkey withdrawal to serve as a warning. I used to say recreational benzo use wasn't a thing, but apparently it is. But they at least--the ones I've seen at least--are smart about how they use them versus indefinite, chronic prescribing. That video is about as good as you can get with informed consent and turning people away. I honestly would rather have been guided by a recreational drug user than the guidance I got professionally on benzos. When you say that people can't just give in to what patients want, I would push back and say that it was solicitation of benzos that caused the problem to begin with. I was taken by the safetaper.com web-site copy saying "SafeTaper was created to right a wrong." I can't speak to their service, but their ethos spoke to me.

When you say we (you as a doctor) shouldn't just give in to the "wants" and "needs" and should set boundaries, I would put that sentiment right back on Roche and Bausch and tell them: You created this mess, and you are now responsible for creating an off-ramp. I think they should be compelled to create lower dosage forms of their extremely potent benzodiazepines (Xanax, Ativan, etc.) to help facilitate smoother tapers, at the very least. Those are boundaries we should be setting with this industry. They have not been held to account. The tobacco industry was held responsible for its advertising and hiding information regarding the dangers of its products and compelled to create programs to assist in quitting tobacco.

From what I've heard of the VA, it sounds like a culture where there is a lot more recourse for unsatisfied patients than in the private market, so I don't mean to make light of your concerns about the nature of your work more generally.

 

[birchswing]

The NICE guidelines I am undecided on. They say convert everyone to valium basically. The thing is, some people do worse switching to valium instead of just gradual reduction of their current benzo.

Yes, I agree. I had bad results with Valium--perhaps idiosyncratic, but it caused hemodynamic changes which Ativan did not. I do think the manufacturers should be compelled to create lower dosages of the high potency benzos instead of using Valium as mini-legos to taper off with.

I can say this though- ive seen people improperly tapered off benzos, but have yet to see them shoot people as a result.

My image of what it's like to be cold-turkeyed comes from having read accounts of people imprisoned who were benzo tolerant and not allowed to take medicines until seeing a prison doctor which resulted in them developing what sounded to me like psychosis, "acting out," being isolated, and dying in some cases. I haven't seen it up close and personal. But I extrapolated that if that's what happens in the confines of an enclosed cell, a person might "act out" more aggressively in the free world.

 

[Fan_of_Meehl]

There needs to be more consensus on guns. Progressives, which is the side I'm on, often talk about the number of guns, which ignores the fact that Switzerland has a very high gun ownership rate and isn't plagued with the violence of the US. But of course Switzerland does not have all of the economic despair so many face in the US which I think is directly related to mental health if not mental illness. And economic despair is not something you hear conservatives talk about a lot. They do trot out mental health help when they are mass shootings, and I don't know what that means in tangible terms, but I say if it's sensical it should be taken up. I think Mike Pence even brought out the ideas of asylums, and if they're serious about that, I don't see what would be bad about modern, humanistic asylums. That seems very progressive. But I also think you have to take economic despair into account.

Without change to mental health, to culture, to economic justice, I think a case can be made that the US collectively is not capable of having the latitude of gun ownership permissiveness that it does, which goes back to the liberal cause of gun control through limiting the types of guns on the market. Maybe we just aren't responsible enough collectively, and yet it can at the same time be true that a country like Switzerland is. Conservatives can be hypocritical of this in their support of stop-and-frisk, which is nothing if not gun control. I don't know enough to comment on the abuses of that system or the racial profiling, but it does speak to the fact that crime in the US that in other countries would be petty crime often involves guns escalating the nature of the crime in the US, for cultural reasons I don't entirely understand. I guess it's a self-fulfilling arms spiral. But why is a policy like stop-and-frisk in urban areas tolerable to conservatives but not limiting the type of weapons people own?

But how many benzo naive people come to psychiatrists begging for benzos? When you say no, is it ever to someone who has never been on a benzo before? Or is it someone who was put on a benzo and is now sick because of it?

WIth opioids there's always the debate about whether it's more iatrogenic versus recreationally induced. I don't see how that debate can be had with benzos. If someone wants to just intoxicate themselves, alcohol flows freely.

If you look at reddit's recreational benzo forum, the very top pinned post is a video of a person in the thralls of cold-turkey withdrawal to serve as a warning. I used to say recreational benzo use wasn't a thing, but apparently it is. But they at least--the ones I've seen at least--are smart about how they use them versus indefinite, chronic prescribing. That video is about as good as you can get with informed consent and turning people away. I honestly would rather have been guided by a recreational drug user than the guidance I got professionally on benzos. When you say that people can't just give in to what patients want, I would push back and say that it was solicitation of benzos that caused the problem to begin with. I was taken by the safetaper.com web-site copy saying "SafeTaper was created to right a wrong." I can't speak to their service, but their ethos spoke to me.

When you say we (you as a doctor) shouldn't just give in to the "wants" and "needs" and should set boundaries, I would put that sentiment right back on Roche and Bausch and tell them: You created this mess, and you are now responsible for creating an off-ramp. I think they should be compelled to create lower dosage forms of their extremely potent benzodiazepines (Xanax, Ativan, etc.) to help facilitate smoother tapers, at the very least. Those are boundaries we should be setting with this industry. They have not been held to account. The tobacco industry was held responsible for its advertising and hiding information regarding the dangers of its products and compelled to create programs to assist in quitting tobacco.

From what I've heard of the VA, it sounds like a culture where there is a lot more recourse for unsatisfied patients than in the private market, so I don't mean to make light of your concerns about the nature of your work more generally.

"But how many benzo naive people come to psychiatrists begging for benzos? When you say no, is it ever to someone who has never been on a benzo before? Or is it someone who was put on a benzo and is now sick because of it?"

I'm not sure I can discern or follow your point here. Benzo's can be drugs of abuse, regardless of the circumstances under which the person had their first dose provided to them.

"When you say we (you as a doctor) shouldn't just give in to the "wants" and "needs" and should set boundaries, I would put that sentiment right back on Roche and Bausch and tell them: You created this mess, and you are now responsible for creating an off-ramp. I think they should be compelled to create lower dosage forms of their extremely potent benzodiazepines (Xanax, Ativan, etc.) to help facilitate smoother tapers, at the very least. Those are boundaries we should be setting with this industry. They have not been held to account. The tobacco industry was held responsible for its advertising and hiding information regarding the dangers of its products and compelled to create programs to assist in quitting tobacco."

Maybe the prescribing provider who is currently seeing the person who was initially prescribed benzodiazepines isn't the same one who 'created the mess' and who is instead trying to do the right thing and (a) practicing according to an overarching ethic that doesn't have a half-life of the benzo; (b) actually acting in accord with best practice guidelines. I totally agree that it'd be great to develop any technology (including 'lower dosage forms') to facilitate smoother tapers (but I lack the specific prescribing experience or pharmacological knowledge to determine if that is practical or worthwhile).

 

[annoyedpsychiatrist]

Yes, I agree. I had bad results with Valium--perhaps idiosyncratic, but it caused hemodynamic changes which Ativan did not. I do think the manufacturers should be compelled to create lower dosages of the high potency benzos instead of using Valium as mini-legos to taper off with.

My image of what it's like to be cold-turkeyed comes from having read accounts of people imprisoned who were benzo tolerant and not allowed to take medicines until seeing a prison doctor which resulted in them developing what sounded to me like psychosis, "acting out," being isolated, and dying in some cases. I haven't seen it up close and personal. But I extrapolated that if that's what happens in the confines of an enclosed cell, a person might "act out" more aggressively in the free world.

Ill just quote this one and respond to you in one post. Someone may have increased anxiety and irritability, but to pull out a hand gun and kill people..That is just not realistic of benzo withdrawal. Even if you say it caused him to have psychosis, its not exactly common that psychotic people pull out handguns and shoot people, especially after being turned down for ativan. This was clearly reactionary in nature. This was not unprovoked psychosis.

While i wont argue that there are good people who get addicted to benzos, there also many malignant people who get addicted as well. It goes both ways. The fact that theres a reddit where people discuss how to misuse benzos just shows how addicted people can become. If anything it further proves my point that we should find a way to stop the flood of benzos. Its not uncommon a person has been prescribed stupid doses of benzos and they get sent to me clean up other providers messes they have caused. Just because someone is addicted to benzos does not mean they will be addicted to alcohol, and vice versa.

The fact is most of us psychiatrists genuinely care about our patients. At least I do. But I encounter a lot of not so good people as well who attempt to use intimidation and threats as a means to get what they want. And tbh with you, i think we deserve better then that, and that these people shouldnt get away with it.

 

[TheRightMedication]

I wonder by what mechanism a lack of benzodiazepines causes murder?

 

[annoyedpsychiatrist]

I wonder by what mechanism a lack of benzodiazepines causes murder?

it precipitates latent antisocial personality disorder

 

[Attending1985]

Without all the info can’t say what was going on here but hearing about these stories over and over makes me afraid to be a doctor especially a psychiatrist. Makes me think about training in something lower risk like sleep medicine or public health as things seem to just continue to get worse.

 

[Sushirolls]

it precipitates latent antisocial personality disorder

This ^^^^

Personal responsibility. Psychiatry and its adjacent mental health specialties are diminishing personal responsibility. Embracing victimhood and perpetuating the lack of control due to mental health. Wrong, wrong direction to go.
Not the guns.
Not the meds.
Not the docs.
The person who kills others... we have ropes, firing squads, and injectables to terminally carry out a preferred judicial sentence.

For so many people we should still be utilizing the criminal justice system. Floridly manic? running down the freeway? Yes, courts should be involved. Why? because of people don't have consequences they are more inclined to discontinue meds.

I can't tell you how many patients I've had over the years reflect on their time on the streets, doing drugs, being homeless, and a big part of their sobriety and continued recovery now, is in part due to being tired of getting locked up and interacting with law enforcement. They just got tired of the cycle. And here we are in deep blue states going the opposite direction of de-criminalizing drugs. Not arresting homeless people. All these folks, deserve our respect, and the level of respect means not treating them as victims but treating them with the same degree of responsibility we hold for ourselves and that also means judicially.

So much in mental health is treatable. Recovery is possible. Stability is possible. Perpetuating and re-enforcing victim / disabled status in people does them a disservice, and disrespectful.

What has worked in the past, will work again (as it continues to do in some states). Arrest people. Put them in jail, enforce the sentences.

For years I've drank the Social Justice Koolaid that we need to decriminalize drugs, diminish the consequences, treat things as just an illness, and move further from the judicial system - emphasize treatment, treatment, treatment. Nope. Not working. Wrong direction.

 

[Candidate2017]

I wonder by what mechanism a lack of benzodiazepines causes murder?

The literature shows there's an association, not necessarily causation, with lack of benzo occupancy at GABA receptors and an increase of serum levels of eye-dee-eye-oh-tee in individuals with pre-existing elevated levels.

 

[PsyDr]

it precipitates latent antisocial personality disorder

Is it latent if you were charged with domestic violence, hit and run, and possession of marijuana... before one ever joined the Coast Guard?

 

[annoyedpsychiatrist]

Is it latent if you were charged with domestic violence, hit and run, and possession of marijuana... before one ever joined the Coast Guard?

So he had a clear violence history? Its interesting how the news fails to manage that part...

 

[docksan]

So he had a clear violence history? Its interesting how the news fails to manage that part...

Yes but this is just par for the course when it comes to news. While his past doesn't necessarily define him, it's pretty egregious to leave out "by the way he was a pretty violent person already" from the words "he would have been fine if they just gave him the Ativan, I'm a nurse".

 

[Geraltofrivia]

<Not a doctor or medical student>

Reading between the lines, he was on the Ativan, then off of it and some other med put in place as a replacement (the one referenced as started on Friday), and he wanted to go back on the Ativan?

That's just parsing the very limited data in the article.

The VA guidelines are incredibly rapid with regard to benzo withdrawal compared to the NICE guidelines, for example, and specifically don't mention patient autonomy which the Ashton Manual on which the NICE guidelines were largely based mention as paramount. I don't think you could rule out homicide/suicide as an effect of withdrawal. People can go into frank psychosis from withdrawal. I recently came across safetaper.com —california based outfit for de-prescribing in a more informed way based on a modified Ashton approach. I was not impressed with the VA's guidelines when I read them.

And I can't count the number of times I've seen medical authorities write that all manner of psychiatric drugs like SSRIs can be used for the "rebound anxiety" which in my opinion isn't rebound anxiety at all—rebound anxiety would be nothing compared to benzo withdrawal, and I don't even know how anyone can claim to see it in a distinguishable state in the fog of withdrawal symptoms.

My gut instinct is to blame the pendulum swings with policing of drugs. I would bet dollars to donuts he had been on them for a prolonged period and taken off, that this was not a benzo-naive demand. I could be wrong—there's that odd detail about the truck running waiting, which seems very deliberate. But the way the mother referred to it as "his Ativan" makes me think he had been on it for some time.

I'm not familiar with NICE protocol but I don't think, at least didn't, 15 weeks is "incredibly rapid"

https://www.va.gov/painmanagement/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf

 

[hamstergang]

What has worked in the past, will work again (as it continues to do in some states). Arrest people. Put them in jail, enforce the sentences.

So the whole "war on drugs" has been successful at reducing substance use?

 

[Sushirolls]

Nope it hasn't.

But going in the opposite direction and turning a blind eye, to not enforce crimes or laws isn't working either. Go walk the streets in places like Portland or Seattle. Drive around the towns. Feels like I'm India or another foreign country. The difference is, we have laws in most counties/parishes that limit the ability to put up walls with barbwire around your home to keep criminals at bay.

Capital punishment doesn't work either. Iran still hangs people frequently for opioids. Heck, even people in Saudi are quietly brewing and drinking in the country that has laws that will kill them for it.

Damned if you do, damned if you don't, but the lesser of two evils is the old/traditional way. Use the judicial system.

 

[littlefred]

Nope it hasn't.

But going in the opposite direction and turning a blind eye, to not enforce crimes or laws isn't working either. Go walk the streets in places like Portland or Seattle. Drive around the towns. Feels like I'm India or another foreign country. The difference is, we have laws in most counties/parishes that limit the ability to put up walls with barbwire around your home to keep criminals at bay.

Capital punishment doesn't work either. Iran still hangs people frequently for opioids. Heck, even people in Saudi are quietly brewing and drinking in the country that has laws that will kill them for it.

Damned if you do, damned if you don't, but the lesser of two evils is the old/traditional way. Use the judicial system.

Yeah let's also use the judicial system on the mentally ill homeless persons. How dare they not seek treatment or take their meds, it's so easy!
You talk as if having a substance use disorder is a choice which is very odd given your training.

 

[TheRightMedication]

We could have both - a robust judicial system and also well funded treatment. Do we not, in our own work, maintain very strict boundaries, ensuring bad behavior has consequences, while simultaneously offering aid?

 

[clausewitz2]

We could have both - a robust judicial system and also well funded treatment. Do we not, in our own work, maintain very strict boundaries, ensuring bad behavior has consequences, while simultaneously offering aid?

I mean, this is how Portugal does it. Decriminalization of basically everything there does not mean a free for all, it means actually funded court-mandated treatment instead of jail.

 

[calvnandhobbs68]

We could have both - a robust judicial system and also well funded treatment. Do we not, in our own work, maintain very strict boundaries, ensuring bad behavior has consequences, while simultaneously offering aid?

Right a lot of my adolescents wouldn't do jack **** about substance use until they end up caught by the school or judicial system...so yeah doesn't mean throwing them in jail for it but does mean you have some teeth in order to enforce treatment programs. I can MI all day long but they're mostly like "yeah whatever dude" until they actually see negative downstream effects all the while frying their brain with whatever drug of choice they're on. Can certainly help resolve that ambivalence about change for some of them ha.

 

[bGMx]

Just going to echo what the above is saying. Understanding, communicating, and conducting human affairs deterministically on a societal level is not mutually exclusive with having a robust system of consequences which incentivizes acceptable behavior and disincentivizes unacceptable behavior. I think those two views are entirely compatible. Frankly, I wish the public understood it better, rather than thinking people are "born evil, or born evil and then baptized."

 

[Fan_of_Meehl]

So the whole "war on drugs" has been successful at reducing substance use?

My observation has been that national-level 'Wars on Anything' inevitably result in more problems in the area being attacked that when the 'Wars' began. We must be attacking these problems with fertilizer.

 

[whopper]

Maybe we just aren't responsible enough collectively, and yet it can at the same time be true that a country like Switzerland is.

I'm not sure if you're using Switzerland in the proper context because in so many false-arguments it's been inappropriately pushed. I'm not blaming you because several have used in in their push for misinformation.

E.g. some sources with the full intent to mislead cite Switzerland as an example of a place where several people have guns yet gun-related problems are very small hence everyone in America should have a gun and there be very little restriction.

The problem is 1-in Switzerland the people required to undergo training for said guns are much higher than American standards, 2-several of those figures reflected Swiss men who were in the military (where military service is required for men) and law enforcement and in several of those cases these same men were required to keep the firearm at the base and not take it home. 3-The regulations such as a national registry for all gun owners with strict protocols of who can have their guns taken away are no where as open and liberal (not in a left-wing sense) as American standards.

Then add to the mix that Switzerland has much better and readily available access to health services, and it still has one of the highest rates of gun related deaths for Europe.

Yet despite this several of these misleading sources still push the Swiss example while often times citing everyone should have guns, less regulations, and that everyone having guns will solve almost every problem.

Switzerland has a stunningly high rate of gun ownership — here's why it doesn't have mass shootings

Here's what the US can learn from Switzerland, which has nearly eliminated mass shootings while maintaining a high rate of gun ownership.

www.businessinsider.com

 

[Shikima]

Sociopaths gonna sociopath.

 

[Ceke2002]

While I agree that withdrawal is too easily precipitated at the VA, Ativan without context is almost never universally prescribed for anxiety there. It's probably more likely the veteran came in on it and it was continued, or they were prescribed it for withdrawal management (alcohol), OR were seen by a non psychiatrist who started it because they're not a psychiatrist and don't know better. It could also be it was stopped because he violated protocol and it couldn't be continued. It's very clear he was dependent.

But withdrawal resulting in homicidal or suicidal behavior, even psychosis? Not on the regular, and if the psychiatrist thought that and didn't address it then that's a very, very bad doctor because there are several layers of protocol that prohibit you from not addressing high risk patients when they're in crisis.

I'm more inclined to believe the fault lies with the mother for not fully understanding the situation, but could consider the system failed since it does happen.

I did experience a temporary psychosis after sudden withdrawal from Xanax, but certainly not in the way that I could've formulated, let alone carry out a plan to shoot people. The first day and a half of full withdrawal was basically me walking around my house like it was a giant not so fun house amusement park ride, being very confused and thinking I could telepathically commune with fish.

Honestly this incident to me just reads like massive amounts of entitlement and anger issues, possibly with a dose of sociopath thrown in for good measure, resulting in some a-hole throwing the mother of all hissy fits.

Of course if more information comes to light I might change my opinion for whatever it's worth.

 

[docksan]

Right, hence not "on the regular".

 

[TheRightMedication]

Murder is diagnostic for antisocial personality disorder, no?

 

[whopper]

Sociopaths gonna sociopath.

Agree, but if they can get access to a gun or knife that's a difference.

 

[Ceke2002]

Right, hence not "on the regular".

Yeah, sorry I was agreeing you, just in a very long winded way (in case that wasn't clear before). I've been trying to find any sort of scientific articles and/or studies that would suggest homicidal ideations and/or actions in benzo withdrawals, but aside from withdrawal induced delirium or psychosis I''m drawing a blank. The only mention I've even found of potential homicide is on benzo reform type web sites, with zero links to actual data.

 

[annoyedpsychiatrist]

Yeah, sorry I was agreeing you, just in a very long winded way (in case that wasn't clear before). I've been trying to find any sort of scientific articles and/or studies that would suggest homicidal ideations and/or actions in benzo withdrawals, but aside from withdrawal induced delirium or psychosis I''m drawing a blank. The only mention I've even found of potential homicide is on benzo reform type web sites, with zero links to actual data.

Lately when someone does something bad its a "mental health issue". The reality is that there just bad people in this world who do bad things

 

[Fan_of_Meehl]

Murder is diagnostic for antisocial personality disorder, no?

Maybe not diagnostic but I'm certain that those with APD are statistically 'over-represented' in the subset of our population who commit murder.

 

[docksan]

Murder is diagnostic for antisocial personality disorder, no?

Remorseless murder, perhaps. It's the lack of remorse or regret that is diagnostic for antisocial. Anyone can commit murder. An antisocial person is more likely to do it because they're less likely to care about it.

 

[TheRightMedication]

Diagnostic was an exaggeration - I meant there is a high post-murder probability of antisocial personality disorder.

 

[Ceke2002]

Lately when someone does something bad its a "mental health issue". The reality is that there just bad people in this world who do bad things

Agreed wholeheartedly. The whole ''But my mental illness" as a catch all for avoiding responsibility for one's actions is a bit of a pet peeve of mine.

 

[smalltownpsych]

Yeah let's also use the judicial system on the mentally ill homeless persons. How dare they not seek treatment or take their meds, it's so easy!
You talk as if having a substance use disorder is a choice which is very odd given your training.

Risk factors for addiction are not really a choice. Continuing to use and not seek treatment despite negative consequences is a choice. It’s kind of like having risk factors for heart disease and not making any lifestyle changes, kind of your own fault when you die. Also, not staying clean and sober and doing what it takes to continue this is a choice. I also think societal factors can affect probability of what choices are made and much of what we seem to be doing lately is encouraging more unhealthy choices. I like to remind my patients that all psychoactive drugs can be bad for you just to help tip the scale a little bit since it seems like this key point has been getting a little lost.

 

[Ceke2002]

Risk factors for addiction are not really a choice. Continuing to use and not seek treatment despite negative consequences is a choice. It’s kind of like having risk factors for heart disease and not making any lifestyle changes, kind of your own fault when you die. Also, not staying clean and sober and doing what it takes to continue this is a choice. I also think societal factors can affect probability of what choices are made and much of what we seem to be doing lately is encouraging more unhealthy choices. I like to remind my patients that all psychoactive drugs can be bad for you just to help tip the scale a little bit since it seems like this key point has been getting a little lost.

Gotta say I agree with you on this one. It's not like I woke up one day and just randomly decided to become a junkie, but once I was addicted it also wasn't like someone forcibly drove me to my dealer's, then physically restrained me and injected heroin into my arm. Of course things like the intensity of psychological cravings have to be taken into some consideration, but at the end of the day I did still have a choice to keep using or get clean, even if it took me a while to actually see that.

Officially hit my 20 years clean milestone last year as well, that wouldn't have happened if I hadn't truly decided to get real with myself and actually make the decision to commit to a treatment program and stop faffing about with my constant 'woe is poor old junkie me' song and dance routine.

 

[clausewitz2]

Gotta say I agree with you on this one. It's not like I woke up one day and just randomly decided to become a junkie, but once I was addicted it also wasn't like someone forcibly drove me to my dealer's, then physically restrained me and injected heroin into my arm. Of course things like the intensity of psychological cravings have to be taken into some consideration, but at the end of the day I did still have a choice to keep using or get clean, even if it took me a while to actually see that.

Officially hit my 20 years clean milestone last year as well, that wouldn't have happened if I hadn't truly decided to get real with myself and actually make the decision to commit to a treatment program and stop faffing about with my constant 'woe is poor old junkie me' song and dance routine.

In the philosophy of psychiatry literature Hana Pickard has a paper about responsibility without blame. She points out that we don't want to put moral opprobrium on people dealing with addiction, but to say there is not a strong element of choice is very strange, since if addicts genuinely could not choose not to use, none of our current treatment models are coherent. They are all predicated on the idea of the person in question having the ability to do otherwise. The trick comes in reconciling that with the fact that moral philosophy tends to say that people are blameworthy to the extent that they do things that are bad when they could have done otherwise. She takes a decent stab at reconciling this with the intuition that substance abuse in and of itself does not make someone a bad person and blame seems to be counterproductive. It is an interesting needle to thread but I think the dilemma is inescapable.