Finally, the families of LEO’s and first responders who die by suicide are being afforded line of duty death status and the dignity they deserve

First, New Hampshire, and now on July 16, 2022 the City of Chicago, IL has agreed to pay line of duty death (LODD) benefits to officers who die by suicide. Each of these cases are complex and I am sure some form of assessment of the individual officer’s case will be carefully chronicled. I can imagine this is going to be slow going.as I am not sure whether there are some strings attached to the individual suicide. 

Two Capitol police officers have taken their own lives since the insurrection at the U.S. Capitol on January 6, 2021. More recently, three Chicago PD officers have died similarly in their role protecting the city of Chicago. And there have been others who died alone with their private torment.This change in policy will signal to officers that you are not alone and your life has value.

This information came after the two officers spent 5 hours fighting the insurrectionists sometimes in hand to hand combat often being humiliated and threatened. In its aftermath many law enforcement officers and even the secret service detail guarding Vice President Mike Pence were in fear that there may be a blood bath in the Capital that day. Pence was very close to the leading wave of insurrectionists. Jeffrey Smith, a Metropolitan D.C. Police officer, and Capitol Police Officer Howard Liebengood both “took their own lives in the aftermath of that battle” of January 6, according to an article in Politico on January 27, 2021. Over a year later, Officer Smith’s death was changed to line of duty death after significant persuasion by Officer Smith’s surviving wife. Smith had never been right in the few days after the attack. He was ordered back into work in a move that failed to recognize his cognitive deficits and their impact on personal well-being and state of mind resulting from the insurrection.

The denial of this LODD recognition diminishes the honor of one man’s service and by doing so, fails every man or woman who puts on a uniform by saying “your experience is yours alone”. And even worse, it amplifies the stigma attached to law enforcement deaths at a time when all else has failed them and their families. Michael Sefton, 2019

“Chicago is kind of like ground zero with the number of suicides that are happening on a monthly basis now at this point,” said Daniel Hollar, who chairs the department of behavior and social science studies at Bethune-Cookman University in Florida. Dr Holler hosted Dr Doug Joiner to Chicago for a symposium on 2019. Dr Joiner taught us much of why officers kill themselves. He says they become embittered, they feel a deep sense of thwarted belongingness and grow increasingly detached with and higher  risk. “These are people who are answering calls of duty to protect lives. We (need to) do our job to make their jobs safer.” After an officer suicide, personnel try to reconstruct what was going on in the person’s mind by systematically asking a set of questions, in a consistent format, to the people with the greatest insights into the person’s life and mind—family, co-workers, and friends.” This is known as a psychological autopsy. I have been writing about this for 9 years in these pages. This must include a 3 month list of calls the decedent answered including those for which he or she were given debriefing, defusing, or time off for respite from the job. I would want to understand how the call volume may have triggered underlying acute stress of were there calls that triggered new trauma?

Do people recognize signs of depression and someone who is feeling like he no longer belongs.When this is a parent officers have a duty to warn. Many officers have peer support trainjng, or crisis intervention training, or he has RAP and private clinicians to receive support and to handoff the police officer to the professional. I am curious what signs are present in the officer who has planned to take his or her own life? As psychologists we are trained to ask directly: “are you thinking about suicide?” Peer supporters must get better at this and make the band-off to either the EAP or another behavioral health provider. 

NH Governor Sununu signed House Bill 91 on July 8, and it goes into effect Sept. 6. Sponsored by N.H. Rep. Daryl Abbas, R-Salem, it drew bipartisan support. He is the Link:

  https://www.concordmonitor.com/NH-to-provide-line-of-duty-death-benefits-when-first-responders-die-by-suicide-47272823

The New Hampshire law will go into effect on September 1, 2022 and allow officers to feel that their families are secure with benefits of They should die in the line of duty which now include dying by suicide.

Chicago PD and its approximate 13000 men and women officers respond nightly to calls for service involving shootings, deaths, and officer involved shootings or other physical scenarios that puts them in the direct path of violence.

Dr Hollar is organizing the forum in Chicago the first of these I participated in with my colleague Dr Leo Polizoti from the Direct Decision Institute, Inc. in Worcester, MA. Among the issues up for discussion is what role Chicago’s relentless violence problem plays in officer suicide. Hollar said they will also talk about other factors, including whether familiarity with death makes suicidal officers more likely to follow through with their plans as reported in the March 2022 Chicago Tribune.

“What we see in this career, the calls that we get, can take a toll on somebody’s mental health and wellness,” he said Monday. “When we go to a death of a child by the hands of a parent, or a pretty nasty accident scene, these things will add up.” Cheshire, NH Sheriff Eli Rivera

Sometimes a law-enforcement officer will begin to question whether they may have arrived at the scene earlier by driving faster, or whether there was something else they could have done to prevent a loss of life, said Rivera. This can add up to behavior that may place an officer at risk if he decides he needs to get on scene faster the next time around. Some begin to believe that the world may be better if without them. Many are angry and become hopeless and embittered for a variety of reasons, like feelings of resentment and misunderstanding.

The psychological autopsy is especially important when first responders and essential workers are involved and die soon after. When LEO’s and first responders are put in fear of death or see other officers being placed in the direct line of fire, are vastly outmanned, and have no way in which to stop an attack, they are at high risk for the “hook” that comes from an acute stress reaction and over time may become a monkey on the backs of so many fine men and women. They are now free to come out of the shadows.

Roadside memorials and people who maintain the shrines we see on roads everywhere

Roadside memorial

I am always in awe when I drive past roadside memorials. They commemorate the place where someone was killed in a motor vehicle crash. They grew in popularity following the of MADD, Mother’s Against Drunk Driving first in the 1980’s in Austin, Texas. These are usually a white cross along with trinkets, toys, and photos that memorialize them life or lives that were lost at the location. Many are painted with the names of people who have lost their lives too. What strikes me is who maintains the site? Is there any sort of memorial at a internment site? Do the same people who maintain the shrines also maintain a grave site?

There is a psychology to the roadside memorials that are dotted across our country’s roadways commemorating the lives of people who have perished. Usually these are simple crosses sometimes emboldened by the name or names of people who may have been in fatal accidents at the location. Others grow to become memorials to a lost love one and are maintained by grieving family members. I seem to see them everywhere and wonder about the survivors. Do they visit the site? It is different then a cemetery in that this is not the place where they were laid after death, but this is the last place on earth their loved one was alive. 

I am reading a couple of books about roadside memorials with interest. One is a thesis from a Canadian university, authored by Holly Everett from Memorial University in Newfoundland. These sites are also known as the “spontaneous shrines” that result from a public outpouring of grief according Everett who studied the shrines in Texas as part of her graduate work. It makes me sad when someone builds a spontaneous shrine to honor the loss of someone. On my way to work a few months go, I noticed that 2 crosses were erected in a tree near my home. A spontaneous shrine.

While working as a police officer I noticed these spontaneous shrines popping up in our town usually after a fatal accident. Fortunately, we had very few fatal crashes in the 12 years I worked. Towns everywhere, including the one in which I patrolled, were discussing regulations about the roadside crosses and all the stuff that accumulated along with them. Our chief was sympathetic but the one or two shrines in our town became a traffic hazard in his mind. Cars (I assume family members or friends) would slow or stop for a short visit. We always worried about someone getting injured or killed on the site of one of the crosses. And we had a call to the cross on Rt 67. The boyfriend of one of the victims was sleeping at the cross site. Upon further investigation we learned that he was so grieved that he wanted to stay with the girlfriend’s cross one last time. Sadly, we had to send him along because having a sleeping person on a busy road caused too much public concern. Communities are needing to regulate these sites because the grieving public tends to add more and more to them. Some family members even mow grass or shovel snow keeping the site looking prosperous. According to the draft policy posted on the BBC site, “locations and content of roadside memorials will be vetted for safety and messages that can be considered “offensive” will be banned, as will any sort of illumination or materials that can shatter, such as glass” January, 2022

It struck me that the first names were imprinted on white crosses leaving off the last names of the two boys who died at the site. I would have liked to know the last names. I wanted offer my condolences in some way. Maybe I had seen them riding bikes in the neighborhood just recently, at least until one of them earned his driver’s license.

Treatment Resistant Depression and it’s impact on life: looking toward more contemporary options in 2022

Intractable depression now has multiple options and hope for its resolution – read on

Intractable depression is something that occurs in 20-30 percent of patients with major depression. It is called treatment resistant depression or TRD according to Zhadanava M, Oilon, D,Ghelerter I, et al. (2021). There are more medications than ever and a range of programs for treatment resistant depression that some may not have heard about. For that reason this review will be useful.


As the name implies, treatment resistant depression is highly refractory to the typical treatments that generally include psychopharmacology and psychotherapy. I have had the clinical opportunity to meet with men and women in psychotherapy who are diagnosed with major depression but for some of them, nothing has helped. They have had multiple trials on numerous medications and psychotherapy with little to no relief of symptoms. Some describe a worsening of symptoms after beginning treatment and some claim this to be signs of an allergic reaction to the medication. The British Journal of General Practice has published a list of the first line antidepressants in 2019, Kendrick,Taylor, and Johnson. The meta analysis is conducted in 2019 revealed 21 medication’s that showed efficacy and tolerability in patients with it it may be depression. They found agomelatine, (Valdoxan), amitriptyline – a tricyclic antidepressant but is prescribed for various nerve, arthritis, and muscle pain, escitalopram (Lexapro) – may treat generalized anxiety as well as depression, mirtazapine (Remeron), used for poor sleep hygiene, failure to thrive, and major depression, paroxetine, (Paxil), venlafaxine, (Effexor) may help with GAD and panic anxiety, and vortioxetine (Trintellix) more effective than others.

These patients are intractable in their sadness and become resolute that nothing will help them. Most have been talkative, intellectually curious, but deeply sad in my presence. They are often hopeless that they may never feel a few moments of joy each day, no matter what they do. Many feel embarrassed for being so overwhelmed with life and barely hold on from week to week. Others take life with little hope that things will ever change and, for them, suicide is always on the drawing board. These few patients sometimes need a more structured living arrangement, usually a hospital.  Many patients with intractable depression live life with their final exit all cued up and ready to roll. Some plan to move west to states like Oregon that has physician assisted suicide – saved for when they can no longer live with themselves. For these people, I work with them to find a greater purpose upon which to focus and measure success – often one day at a time. In addition to psychotherapy it is important to get these folks moving with rigorous exercise and activities to find greater purpose. Some patients decide to return to school, work or start attending church again. This programs not only enhance dopamine transport but they also result in social interpersonal contact, something many are missing as they grow older.

There are now new and controversial treatments for treatment resistant depression that are being reported in the psychiatric literature bringing hope to families everywhere. Treatment like transcranial magnetic stimulation, ketamine treatment, stellate ganglion block, deep brain stimulation (requires a surgical procedure to set a deep brain stimuator in the area of the brain that subserves the aura of well-being, and even psilocybin, a powerful psychedelic. Family members sometimes ask why can’t we do something less invasive? The transcranial magnestic procedure is non invasive and uses strong magnetic fields to stimulate neurons within the brain in the area that underlies mood regulation. Treatment requires 15-30 sessions. Readers may have heard little about these treatments, but for families who have watched their loved ones languish, they offer a modest hope that life for their loved ones now has options and promise. These are the cases that you worry about at the end of the day. These are the cases that may not buy what you are selling when it comes to a therapeutic modality or trial of medication that they have already tried and failed. The handoff to one of theses specialty options including ECT – electroconvulsive therapy needs to be a careful one and deep brain stimulation requires sensitivity and cautious optimism about the likelihood of success. A little halo affect can go a long way in getting a good first impression, and a good start to a new treatment modality. A careful history about what medications have been tried and failed is important to document including the length of time they took the drug.

Still newer is the return of hypnotic and synthetic therapy. Scientists are using psilocybin to bring patients through their depression in one of two treatments. Reader may understand that psilocybin are the main ingredients in LSD. There is a growing literature on the use of psilocybin to improve depression resistant cases. Those participating in psychedelic studies often say the experience was among the most meaningful of their lives, on a par with the birth of a child or death of a parent. Many report feeling a sense of connectedness with the universe. “This psilocybin journey was the single most transformative experience of my life,” Mr.Fernandez wrote in a medium post in 2018 reported in a recent NY Times opinion piece by Dana Smith, Ph.D (taken 7-16-2022).

I saw the 60 minutes story on SGB a year or two ago as a possible treatment for refractory PTSD. Many patients now matter how many medications the the and even combined with hours of individual psychotherapy still have reactive symptoms of the condition. SGB stands for Stellate Ganglion Block. Ganglion simply means a bundle of nerve fibers. We have numerous ganglia in our bodies. The Stellate ganglion is different and offers a potentially serendipitous treatment option for posttraumatic stress disorder (PTSD) that heretofore has been refractory to conventional psychiatric therapy. It may hold promise for co-occurring depression as well. It involves a neurochemical blockade of the stellate ganglion. The use of a small amount of anesthesia provides a risk free blockade of the autonomic nervous system overflow that contributes to the toxic levels stress hormones like adrenaline and cortisol that directly add to feelings of anxiety and hyperarousal among people with PTSD. This elevated arousal puts them on high alert night and day. This is not sustainable. 

Here in Massachusetts, the MGH has a Stereotactic Functional Neurosurgery Program that among other things does SGB for medically intractable Obsessive-compulsive disorder and Major depression under a current protocol at MGH. Surgical options are not considered until when medical options are no longer effective or side effects may be severe (Functional Neurosurgery Program, Massachusetts General Hospital website, taken August 22, 2022. DBS has been utilized for Parkinson’s disorder for many years. For people who suffer with major depression many are hopeless and believe the world may be better without them in it. These alternative treatments like: ECT, TMS, Ketamine, stellate ganglion block, and DBS afford greater options at some personal cost. While they are intensive and in some cases invasive there is a trade off in terms of quality of life. The tipping point in my view, when people are isolated, hopeless, and their depression becomes a barrier to functional living, like failure to thrive, the cost of not taking a broad approach to treatment is too great. Human suffering can sometimes be so silent that no one takes notice. The treatment resistant are sometimes elderly and often alone. It is these people that I worry about in my practice as a clinician here in Massachusetts.


REFERENCES

Zhadanava M, Oilon, D,Ghelerter I, et al. (2021). The prevalence and national burden of treatment-resistant depression and major depressive disorder in the United States. Journal of Clinical Psychiatry; 82(2):20m13699

Kendrick, T, Taylor D, Johnson, C. (2019). Which first-line antidepressant? British Journal of General Practice; 69 (680): 114-115.

Smith, Dana (2022) Taking the Magic Out of Magic Mushrooms, Opinion, NY Times, July 16, 2022

Agin-Liebes GI, Malone T, Yalch MM, Mennenga SE, Ponté KL, Guss J, Bossis AP, Grigsby J, Fischer S, Ross S. (2020). Long-term follow-up of psilocybin-assisted psychotherapy for psychiatric and existential distress in patients with life-threatening cancer. J Psychopharmacol.Feb;34(2):155-166. doi: 10.1177/0269881119897615. Epub 2020 Jan 9. PMID: 31916890.

MGH (2022) Stereotactic Functional Neurosurgery Program, Website taken 8-22-2022.