The Medicalization of Mental Illness in Gun Violence

By Carolyn C. Meltzer, MD

Dr. Meltzer serves as the William P. Timmie Professor and Chair of the Department of Radiology and Imaging Sciences and as the Associate Dean for Research at the Emory University School of Medicine. Her work focuses on applying novel advanced imaging strategies to better understand brain structure-function relationships in normal aging, late-life depression, and Alzheimer’s disease. She is also involved in oncologic imaging research and, while at the University of Pittsburgh, oversaw the clinical evaluation of the world’s first combined PET/CT scanner. She established the Emory Center for Systems Imaging to broadly support the advance of imaging technologies in basic and translational research, including beta testing of the first human combined MRI/PET scanner. Dr. Meltzer has also served as the Chair of the Neuroradiology Commission and Chair of the Research Commission on the American College of Radiology’s Board of Chancellors, President of the Academy of Radiology Research, Trustee of the Radiological Society of North America Foundation, and President of the American Society of Neuroradiology.

On January 6, 2017, a young man pulled a semiautomatic handgun from his checked baggage and shot and killed several passengers in the Fort Lauderdale airport. In the days following the incident, information about erratic behavior and his prior involvement in incidents of domestic abuse emerged.

Image courtesy of Wikimedia Commons

The US has the highest rates of both gun-related deaths and mass-shooting incidents. In the latest available statistics from the Center for Disease Control and Prevention (CDC), 33,304 people were killed by firearms in 2014. Over the past decade (2007-2016), there have been 16 mass shootings in the US (Mother Jones’ Investigation: US Mass Shootings 1982-2016), including several -- at Virginia Tech, an Aurora theatre, the Sandy Hook Elementary School, Charleston’s Emanuel African Methodist Episcopal Church, and the Pulse nightclub in Orlando – that drew substantial national attention.

Particularly since Sandy Hook in 2012, public and political attention has focused heavily on mental health reporting. Despite stark disagreements on the gun control, public acceptance of restricting gun access to those with mental health conditions is strong and has resulted in registering people with known psychiatric illness in the national background check system (Kangas and Calver 2014). Initial efforts focused on those involuntarily committed and/or ruled mentally incompetent by the courts, yet several states have pushed to include people voluntarily seeking mental health treatment. Unintended consequences of mental health background checks may include discouraging individuals from seeking psychiatric treatment based on fear of breach of confidentiality or restriction of rights.

Image courtesy of Flikr

While sensible on the surface and potentially comforting to a jittery public, attempts to medicalize gun violence may be fraught with peril. A psychiatric disorder is a poor and non-specific predictor of violent behavior and evidence on whether mental illness increases the risk of violence is mixed (Norko and Baronosky 2005; Glied and Frank 2014). While public officials may be quick to denounce as “deranged” or “mentally ill” a shooter who appears to hold an extreme ideology or perpetrates a hate crime or seemingly senseless mass shooting, such features are not necessarily indicative of a psychiatric diagnosis. Despite epidemiological evidence to the contrary, the majority of Americans believe people with schizophrenia are likely to act violently toward another person (Harvard Mental Health Letter 2011). The assumed causality between mental illness and mass shootings can easily become generalized to be the driving force in all gun-related deaths (Metzl and MacLeish 2015). Gun laws focusing broadly on mental illness may further perpetuate this misconception and amplify the public stigma associated with psychiatric conditions.

A greater understanding of the roles and interplay of such factors as mental health, substance abuse, past displays of violence, social stress, and availability of a firearm could be useful in developing evidence-based gun safety policies. Yet federal research into the many variables associated with gun-related injuries is limited by a 1996 Congressional action barring the CDC and NIH from promoting gun control and slashing funds for the CDC firearm injury prevention program. Restricting resources to an important public health matter is both ethically problematic and may discourage young scientists from focusing on an area of study for which no significant funding exists.

References

Follman M, Aronsen G, Pan D. US Mass Shootings, 1982-2016: Data from Mother Jones’ Investigation. Sept. 24, 2016 found here (accessed January 8, 2017).

Kangas JL, Calvert JD. Ethical Issues in Mental Health Background Checks for Firearm Ownership. Professional Psychology: Research and Practice 2014;45(1):76-83.

Mental Illness and Violence. Harvard Mental Health Letter. Volume 27, no. 27, January 2011.

Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients and Firearms. Annals of Internal Medicine. 2016 165(3): 205-213.

Glied S, Frank RG.  Mental Illness and Violence: Lessons From the Evidence. American Journal of Public Health 2014, Vol. 104, No. 2, pp. e5-e6.

Metzl JM, MacLeish KT. Mental Illness, Mass Shootings, and the Politics of American Firearms. American Journal of Public Health 2015;105(2): 240-249

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Meltzer, C. (2017). The Medicalization of Mental Illness in Gun Violence. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/01/the-medicalization-of-mental-illness-in_13.html

The plague at our doorstep: ethical issues presented by the Zika virus outbreak

By Ryan Purcell

Image courtesy of Flickr user Day Donaldson

“Never before in history has there been a situation when a bite from a mosquito can result in such a devastating scenario.” So says Tom Frieden, director of the US Centers for Disease Control and Prevention (CDC). The Zika virus has captured headlines since late 2015, when word spread north from Brazil that a virus, new to the Americas, may be silently causing alarming neurodevelopmental disorders in newborns. Now, the southern United States is preparing to confront the mosquito-borne illness, which “may become the first great plague of the 21st century.” As public health officials continue to work to mitigate the impact of what the World Health Organization has declared a “Global Health Emergency”, there are several important ethical issues that must be considered. These include a women’s reproductive rights, disability rights concerning those most affected, and the growing realization that poverty-stricken regions and neighborhoods will bear a disproportional burden from this disease. Each of these concerns deserves much more attention than could be provided here. My current aim is merely to point out key issues to stimulate discussion.

In a letter to the editor published in February in The Lancet, Monica Roa of American University made a compelling argument for increased attention to women’s reproductive rights in Latin America in response to the Zika virus outbreak. According to Roa, the recommendation by Columbia, Ecuador, El Salvador, and Jamaica for women to delay pregnancy is woefully out of step with the unfortunate realities of life for many women in these countries. For example, the rate of unintended pregnancy is extraordinarily high due to significant cultural and economic barriers to quality sexual and reproductive health education and services. Moreover, rates of sexual violence are particularly high, contributing to “large groups of women who do not have control over their sexual and reproductive lives.” The UN High Commissioner for Human Rights Zeid Ra’ad Al Hussein, also weighed in: “the advice of some governments to women to delay getting pregnant, ignores the reality that many women and girls simply cannot exercise control over whether or when or under what circumstances they become pregnant, especially in an environment where sexual violence is so common.” Further, the virus can remain in semen even longer than in blood, so why are men also not being advised against impregnating women? To make matters worse, access to abortion services is extremely limited (in some countries it is illegal), and where it is an option for women, many do not understand how to access services.

Termination is not necessarily the answer for many women who have been infected with Zika virus during their pregnancy. First, while it has been confirmed that Zika virus infection in pregnant women can cause microcephaly, it does not always do so. One of the many remaining unknowns is the level of risk to the fetus during maternal infection. Even when a fetus is diagnosed or an infant is born with microcephaly, the disorder can have a range of severity and some children, despite smaller-than-normal head size, have no evident disability. Microcephaly is thankfully rare, but because of this it is not particularly well-understood and support services for these children and their parents are limited, even in wealthy countries. Parents of some children with microcephaly point out how their kids live lives consistently above and beyond doctors’ negative expectations for them in terms of quality of life and lifespan.

Head size comparison of a child with microcephaly and a child
with typical brain development, image courtesy of Wikipedia

The headlines bordering upon hysteria have proven especially difficult for some parents of children with the disorder. As one mother wrote, “The endless pounding of Zika stories, and the descriptions of the grim futures that await the families of microcephalic children, chip away at a façade I’ve built by surrounding myself with friends, family, and a community who value and love my son.” For disability rights advocates, the insinuation that microcephalic fetuses should be aborted is frustratingly familiar. Improving access to sexual health services for women in Latin America should be motivated by a desire to allow women to exercise more control over their lives, not to avoid a “dystopian” future of disabled children. Unfortunately, many of the confirmed cases of microcephaly caused by Zika virus are extremely severe and for some of these children the prognosis may indeed be grim. In severe cases, children can experience seizures, have profound developmental delay, and have visual and motor problems, all of which can be lifelong conditions. Though to quote one parent commenter, “I have a child with microcephaly who is witty, loving, adoring, occasionally a pain in the butt, nosy, and giggly. He makes my world so much better…Some of the coverage has been so painful and callous and ignorant.” It is, however, a reality that in resource-limited settings like rural northeastern Brazil where the uptick in cases was first noticed, the disorder will present a tremendous challenge for parents.

Along these lines, an additional disturbing issue that is now receiving increasing attention is that the Zika virus will likely disproportionately affect those who have the least resources to confront it. In the American South, homes in wealthy areas are air-conditioned with screened windows and well-maintained grounds without standing water. In some cities, like Houston for example, poor, economically-depressed neighborhoods provide excellent breeding areas for the urban, Zika-carrying Aedes aegypti mosquitoes. These types of neighborhoods are even more common throughout poorer urban areas of Central and South America, and are predicted to see higher rates of Zika virus transmission. The unfortunate reality that this outbreak may have an outsized impact on disadvantaged neighborhoods is an ethical issue and an expedient response is an ethical imperative. Republican leaders in the US House of Representatives have stalled passage of a funding measure for Zika response. Would those dollars be freed up faster if Capitol Hill inhabitants were bearing the brunt of this epidemic?

Several research groups are currently at work on a vaccine for Zika, but this will take time to reach the market. The need to have a vaccine, especially one that is safe for pregnant women, presents an additional obstacle to overcome. Nevertheless, it is thought that individuals who have been infected – many of whom report relatively minor symptoms, if any – may be immune to future infections, though this remains to be seen. In the meantime, the issues outlined above need to be addressed. There is a great need for improved sexual and reproductive health education and access to services to give women more control over their futures. There is also an urgent need to better understand the risks to the fetus when a pregnant woman is infected, and better or earlier predictors of prognosis for children born with microcephaly. Amid these needs there are plenty of opportunities for positive outcomes from this outbreak – to better understand and accommodate individuals with developmental disabilities, to shine a light on lagging reproductive rights, and to see more clearly what makes certain segments of the population especially vulnerable.

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Purcell, R. (2016). The plague at our doorstep: ethical issues presented by the Zika virus outbreak. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/06/the-plague-at-our-doorstep-ethical.html

Psychostimulants in preschoolers: Panacea or Pandora's Box?

Victoria became pregnant at a young age. During her pregnancy, she was unable to consistently make responsible choices for herself and her developing child, often indulging in alcohol and drugs. As a result, her son Brian was born prematurely at 7 months. By the time Brian entered preschool, he became increasingly difficult for Victoria and his teachers to control, his interactions with other children at times violent and aggressive. Desperately trying to manage Brian’s outbursts, Victoria confides in a child psychiatrist who puts Brian on Ritalin. Within a couple of months, Brian’s outbursts subside, and much to everyone’s relief (Brian’s included), he is now able to sit through his preschool classes with limited distraction. He begins to enjoy relating with other kids and no longer receives negative attention at school. Several years later, Brian, now a very diminutive 9 year-old, writes a paper for a class assignment in which he suggests that everyone should have treatment like him to “make them behave,” and that “all kids with broken brains should have them fixed, too.” When Victoria learns of this, she speaks with Brian, who says he is confused why some kids can “be good without pills,” and wonders if people would “still love him if he stopped taking his.”¹ 

To some, this story tells of the triumph of administering drugs like Ritalin to children with certain behavioral profiles, such as attention-deficit/hyperactivity disorder (ADHD). Before being treated, Brian is uncooperative, anti-social, and unresponsive to linguistic persuasion. His behavioral disposition persisted and continued to worsen before treatment, and his prenatal exposure to toxins suggests that Brian may have suffered neurodevelopmental abnormalities that contributed to his social dysfunction. By comparison, Brian’s treatment is a successful attempt to bring him “up to speed” with his peers: he now exhibits self-control, can develop meaningful relationships, and attends to his schoolwork.

However, to others, this story highlights concerns about identity formation, self-worth, and growth retardation in drug-treated children. The issue is that Brian has begun to realize how he acts, what he thinks, and how he feels are all in some way a result of the treatment, and that this sets him apart from his “good” peers. Brian’s perception of himself in relation to the world around him has been changed in a fundamental way that will shape his identity as he matures. The hope is that Brian’s caretakers will support his healthy exploration of these concepts and reassure him that his worthiness does not depend on drugs. Also of concern is Brian’s stunted growth, which may be a result of long-term Ritalin treatment.

As a whole, Brian’s story illustrates both the successes and perils of psychopharmacological treatment in very young children. With respect to social functioning, there may be clear, long-lasting improvements for some with ADHD; others may fail to respond, or worse, experience adverse side effects. This brings up the issue of safety, which has been studied to a very limited extent in young children and begs the following question: “Despite their psychosocial benefits, how safe are these drugs for the vulnerable brains and growing bodies of preschoolers?” In order to address this question, I’ll provide an overview of the current body of research into the safety and efficacy of these drugs, along with current trends in ADHD diagnosis and treatment.

Methylphenidate, often referred to by its trademark name Ritalin, and amphetamine (trademark Adderall) are by far the most commonly prescribed drugs used to treat ADHD in preschoolers 4-5 years of age. Both drugs are psychostimulants, meaning they can enhance alertness, and have been shown to reduce classical ADHD symptoms of hyperactivity and inattention. While the exact data on how many prescriptions have been issued to preschoolers alone are unclear, the CDC estimates that just over 4% of all children aged 4-10 took psychostimulants as of 2007². Trends have been increasing since the early 1990’s and can be expected to continue. Aligned with this expectation is the American Academy of Pediatrics’ (AAP) October 2011 release of new clinical practice guidelines supporting the use of psychostimulants in 4 and 5 year-olds³, which the CDC also endorses⁴. The AAP claims, “there is now emerging evidence to [prescribe to] preschool-aged children.” What is this emerging evidence, exactly?

Of the two psychostimulant drugs most commonly prescribed to preschoolers (and there are a handful of others), only Adderall has received Food and Drug Administration (FDA) approval for use in children this young (also keep in mind that a clinician may prescribe an FDA-approved medication to treat basically any condition in any person, a practice known as “off-label” usage; so, prescribing almost any drug on the market to preschoolers is fair game). One might expect that FDA approval would be based on studies illustrating that Adderall is safe for preschoolers; however it is worth noting that no double-blind, placebo-controlled clinical trial of Adderall in preschoolers has ever been conducted. This basically means that tens if not hundreds of thousands of children are currently taking a drug without most stringent science to back it up, which even the AAP notes has “little evidence to support its safety and efficacy.” On the other hand, Adderall has been studied and deemed safe for older children (6+ years); however, studies have shown decreased drug metabolism and clearance in preschoolers, making the FDA’s extrapolation problematic⁵.

Ritalin’s effects in preschoolers are better characterized, though the FDA has not officially approved its use in children this young. While a dozen or so studies have examined the effects of Ritalin in preschoolers, only one double-blind, placebo-controlled trial has been carried out. This study, known as the Preschool ADHD Treatment Study (PATS) was completed in 2006 and forms the basis for the AAP’s statement that “methylphenidate is safe and efficacious for children in this age group.” The findings of PATS are encouraging and corroborate the AAP’s claims of efficacy: nearly 2/3 of the 140 children who received 10 months of continual treatment had improvements in ADHD symptomatology⁶. However, some safety concerns were raised. A small number of subjects dropped out of the study due to adverse side effects, but more concerning was that the Ritalin-treated group experienced 20% less than expected height gain, and 55% less than expected weight gain compared to their unmedicated peers. A similar study in older children suggested that growth-suppressed children never catch up to their unmedicated peers⁷, and this effect could be even more pronounced when medication is begun earlier in development.

It is clear that additional research studies are necessary. The aforementioned trials only begin to address issues of safety and efficacy, and given the (increasing) prevalence of ADHD diagnoses, the AAP’s recommendation to its 60,000 clinicians to provide drug treatment seems premature. It is important to mention that the AAP recommends Ritalin as a secondary treatment option; behavioral therapy is first, and ideally combines parent, teacher, and peer-based programs. However, the CDC indicates that over 2/3 of children with ADHD currently receive drug treatment⁸, and a recent study found a 4.9-fold increase in the rate of doctor’s office visits resulting in both an ADHD diagnosis and psychostimulant prescription over the past 18 years⁹. So, either the behavioral therapy isn’t working, or is being bypassed altogether in favor of pills. Keep in mind that behavioral therapy requires a large time commitment by parents and teachers, and the benefits are often not seen for months. In contrast, pharmacotherapy requires relatively little time and energy, and the effects on a child’s behavior may be seen within days. Obviously, the latter option is far more accessible and alluring.

For Brian, we can only hope that his caretakers will continue to closely monitor his behavior and make the best possible decisions with respect to his course of treatment, whether or not that necessitates the use of Ritalin. But not all kids are so fortunate. The reality is that many children are not surrounded by engaged parents and educators willing to put forth the time, effort, and patience required for behavioral therapy. These children, such as those in foster care or from underserved communities, may be particularly vulnerable to being unnecessarily medicated, over-medicated, or both. Evidence for this comes as early as 1999, where data from the Michigan Medicaid system showed that 57% of children aged 3 and younger with ADHD were treated with as many as 22 different medications in 30 combinations and monitored less than every 3 months¹⁰. Although most prescriptions written for preschoolers are psychostimulants, off-label use of antidepressants and antipsychotics is prevalent, and these drugs often have never been tested in young children.

We all want our children and adolescents to thrive and develop into well-balanced, happy adults. This motivation has driven more than two decades of research into ADHD diagnosis and treatment. But it is exceedingly important that we proceed with caution and not be clouded by delusions that a drug, whether now or in the future, will act as panacea. The neurobiological underpinnings of ADHD are complex and vary greatly across individuals. As we have seen, considerable variation also exists in terms of drug sensitivity and metabolism. So while some children have and will continue to benefit greatly from psychostimulants, others will not. Consequently, it is imperative that as ADHD research progresses, scientists and clinicians devote time and resources to developing multimodal treatment strategies that blend behavioral therapy with pharmacotherapy and can be tailored to the individual needs of the child. Multimodal strategies are recognized as the most effective form of treatment for ADHD in children¹¹. On the social level, we must have adequate safeguards in place to advocate on behalf of children most vulnerable to overmedication. We should also be prepared to confidently address the inevitable questions of identity and self-worth that our children will quarrel with, as well as to retrospectively defend our decision to medicate them.

--Jordan Kohn

Emory University

Neuroscience Graduate Program

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Kohn, J. (2012). Psychostimulants in preschoolers: Panacea or Pandora's Box? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/psychostimulants-in-preschoolers.html

1. This story was adapted from Stein Z, Chiesa BD, Hinton C, Fischer KW. “Ethical issues in educational neuroscience: Raising children in a brave new world.” The Oxford Handbook of Neuroethics. Ed. Illes J and Sahakian BJ. New York: Oxford University Press, 2011. 803-819.  



2. Visser SN, Bitsko RH, Danielson ML, Perou R, and Blumberg SJ. (2010) Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children – United States, 2003 and 2007. Morbidity and Mortality Weekly Report. 59(44): 1439-1443. 



3. Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. (2011) Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 128(5): 1007-1022.



4.Recommendations from the American Academy of Pediatrics (AAP). http://www.cdc.gov/ncbddd/adhd/guidelines.html. Accessed 28 Mar 2012.



5. Wigal SB, Gupta S, Greenhill L, Posner K, Lerner M, Steinhoff K, Wigal T, Kapelinski A, Martinez J, Modi NB, Stehli A, Swanson J. (2007). Pharmacokinetics of methylphenidate in preschoolers with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 17 (2): 153-164.



6. Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J, Wigal S, Wigal T, Vitiello B, Skrobala A, Posner K, Ghuman J, Cunningham C, Davies M, Chuang S, Cooper T. (2006) Efficacy and Safety of Immediate-Release Methylphenidate Treatment for Preschoolers with ADHD. J Am. Acad. Child Adolesc. Psychiatry. 45(11):1284-1293.



7. Swanson JM, Elliott GR, Greenhill LL, Wigal T, Arnold LE, Vitiello B, Hechtman L, Epstein JN, Pelham WE, Abikoff HB, Newcorn JH, Molina BS, Hinshaw SP, Wells KC, Hoza B, Jensen PS, Gibbons RD, Hur K, Stehli A, Davies M, March JS, Conners CK, Caron M, Volkow ND. (2007) Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry. 46(8):1015-27.



8. Attention Deficit/Hyperactivity Disorder: Data & Statistics in the United States. http://www.cdc.gov/ncbddd/adhd/data.html. Accessed 1 April 2012.



9. Sclar DA, Robison LM, Bowen KA, Schmidt JM, Castillo LV, Oganov AM. (2012). Clinical Pediatrics. E-pub ahead of print. Accessed 1 April 2012.



10. Rappley MD, Mullan PB, Alvarez FJ, Eneli IU, Wang J, Gardiner JC. (1999). Diagnosis of attention-deficit/hyperactivity disorder and use of psychotropic medication in very young children. Arch Pediatr Adolesc Med. 153(10): 1039-1045.



11. National Resource Center on ADHD: Diagnosis & Treatment. http://www.help4adhd.org/en/treatment/treatmentoverview. Accessed 1 April 2012.