Mental Health

Students who experience traumatic events while growing up in poor, turbulent neighborhoods could be considered disabled, a federal judge has ruled in a high-profile case involving the Compton, Calif., schools.

The ruling from U.S. District Judge Michael W. Fitzgerald, released on Wednesday, involves a class-action lawsuit filed against the Compton Unified School District. The plaintiffs argued that students who have experienced trauma are entitled to the same services and protections that schools must provide to traditionally disabled students.

The ruling wasn’t a complete win for the plaintiffs and the pro bono firm representing them, Public Counsel. Fitzgerald denied, for now, their request for class-action status because, he said, they hadn’t clearly established what’s known as numerosity.

The plaintiffs estimate that roughly 25 percent of the 22,000 students who attend CUSD have experienced at least two or more “severe traumas.” But the judge wrote that exposure to trauma does not guarantee that a child (1) will suffer “from cognizable trauma-induced disabilities for purposes of the proposed class definition, and (2) have been denied meaningful access to their education.”

It’s an important distinction Fitzgerald is making here. He’s not questioning whether exposure to traumatic events can disable a student. He’s saying that exposure to traumatic events does not guarantee disability. And that raises the bar for the plaintiffs as they try to define the size of their aggrieved class.

The court also refused a request to force Compton’s schools to provide additional, mandatory trauma training for staff. The district currently provides some training, but the plaintiffs argued that the program is insufficient.

Legally, this kind of request is an uphill fight. What’s known as a mandatory injunction — ordering someone to start doing something rather than to stop doing it — comes with a much higher standard, one the judge ruled the plaintiffs did not meet.

What happens next depends on both sides and whether this week’s ruling has encouraged any movement to the middle. A settlement between the plaintiffs and Compton Unified is still possible. If not, the lawsuit will move forward.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.

The benefits of talk therapy for depression have been overstated in the scientific literature, according to a study in the journal PLOS ONE.

The finding comes several years after a similar study reached the same conclusion about antidepressant drugs.

Both talk therapy and antidepressant drugs “are efficacious,” says Steven Hollon, a professor of psychology at Vanderbilt University and an author of the study, which was published Wednesday. “They’re just not as efficacious as we think they are.”

For each treatment, researchers found that the apparent effectiveness was inflated by publication bias. This sort of bias occurs when studies finding that a treatment works are more likely to be published than those with a negative finding.

“It’s like flipping a bunch of coins and only keeping the ones that come up heads,” Hollon says. The result is that anyone who reviews the published literature on a particular treatment will see a distorted picture.

The study of talk therapy involved a review of 55 National Institutes of Health grants awarded between 1972 and 2008. The grants paid for clinical trials of psychotherapy for depression.

But results from nearly a quarter of these trials were never published, says Erick Turner, a psychiatrist and researcher at Oregon Health and Science University and an author of both the 2008 study on depression drugs and the new one on talk therapy.

Turner and his colleagues were able to obtain the unpublished results from the researchers who did the trials. “And when you bring in the unpublished data it brings down the apparent efficacy of psychotherapy for depression” by about 25 percent, he says.

The new finding could help reverse an unfortunate side effect of the 2008 analysis of depression drugs, Turner says. After the study came out, it was used by critics of antidepressants to suggest that people with depression should avoid drug treatment.

“There was a wave of just simple antidepressant bashing that went on and has continued,” Turner says. And the results were used to suggest that people with depression should choose talk therapy over drugs.

That made no sense to Turner. “Why should we be recommending this other treatment when it might be just as fraught with publication bias as the drug literature is?”

So Turner was happy to join Hollon and other researchers interested in finding out whether the psychotherapy research had the same bias as drug research.

The result of that effort should reduce unjustified criticisms of drug treatment, Hollon says. “This article if anything kind of evens up the playing field,” he says.

Publication bias may have led psychiatrists and psychologists to be too optimistic about both talk therapy and drug treatment, Hollon says. But he says that’s less likely to be a problem for patients.

“When people are depressed they are usually unduly pessimistic [about treatment],” he says. “The biggest problem we have in depression is getting people to avail themselves of treatment, whatever it is.”

And the act of starting treatment produces a powerful placebo effect, which can make a big difference even if the treatment itself produces only a small benefit, Hollon says.

Of course, publication bias isn’t limited to depression treatments. It’s a widespread problem throughout the research world, says Kay Dickersin, a professor of epidemiology at Johns Hopkins Bloomberg School of Public Health.

“We’re rewarded for getting papers out, for finding results that will bring attention to our universities and to ourselves,” she says. “We aren’t rewarded for being honest; we’re rewarded for making a splash.”

And that presents a challenge both to doctors and to their patients, Dickersin says. “I think the question that’s really arisen is, how much of what’s out there should we really believe.”

One solution, Dickersin says, is to have research grants include a requirement that all study results be made public, even if they’re never published.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.

By the time DeAngelo Cortijo was 14, he had been in more than a dozen foster homes. He had run away and lived on the streets for months, and he had been diagnosed with bipolar and anxiety disorders, attachment disorder, intermittent explosive disorder or posttraumatic stress disorder. He had been in and out of mental hospitals and heavily medicated.

Cortijo, who was born in San Francisco, was taken from his mother after she attempted suicide when he was 3.

After his later diagnoses, he was prescribed a combination of antipsychotics, antidepressants and stimulants, and was told that taking them was his only hope of being normal. Instead, he said, medication made him feel “doped up and completely lost.”

It was not until he spent several months developing a relationship with a horse — “and it was huge,” said Cortijo with a smile — that he began to really acknowledge his own feelings. “Animals sense you, your fears, anxieties and insecurities,” he said.

Finding help through equine-assisted therapy — riding a horse, feeding, grooming and communicating with it — helped Cortijo to gain a better perspective on himself. “It allowed me to understand what a bond was, to realize I am an individual who is capable of caring, capable of being normal,” said Cortijo.

He’s now 22, off all medication, and is helping troubled youth as a juvenile justice intern at the National Center for Youth Law.

Children in foster care are prescribed antipsychotic drugs at double to quadruple the rate of that not in foster care, according to a Government Accountability Office report. Hundreds of children were found to be taking five or more psychotropic medications at a time, although there is no medical evidence to support such a drug regimen. Thousands of children were prescribed doses that exceeded FDA-approved guidelines. The report found monitoring programs for psychotropic drugs provided to foster children fell short of guidelines established by the American Academy of Child and Adolescent Psychiatry.

In March, a report by the inspector general at Health and Human Services found quality of care concerns in more than two-thirds of claims for psychotropic drugs paid for by Medicaid, the health insurer for most children in foster care. That included too many drugs (37 percent); wrong dose (23 percent); poor monitoring (53 percent); or wrong treatment (41 percent). The OIG recommended that the Centers for Medicare & Medicaid Services (CMS) work with the states to enhance oversight, medical reviews and utilization reviews of psychotropics prescribed to children.

In California, a sweeping package of laws to regulate the prescribing of powerful psychiatric medications to children and teens in the child-welfare system has passed the Senate and is heading to the state assembly, where it faces no formal opposition. The reforms also are being eyed as a template for federal legislation. Anna Johnson, a social analyst at the Oakland, Calif., -based National Center for Youth Law, which helped write the legislation, said an enforcement mechanism is needed to change prescribing practices.

“The legislation describes in detail the oversight function — what everyone’s role is, from the juvenile court judge and the social workers, to the care providers, the lawyers, the doctors,” said Johnson. “And it names specifically the prescribing practices we want to see reduced: the use of multiple drugs on children, dosages that exceed maximums and the use of antipsychotics where not medically necessary because of physical health risk factors.”

The push for tougher laws follows last year’s publication of a series of investigative articles in the San Jose Mercury News, which alleged widespread use of antipsychotics and other psychiatric drugs without proper evaluation and monitoring among the estimated 63,000 California children in foster care.

“It is well beyond time for us to be having this discussion and intervening,” said Ken Berrick, president and CEO of the Seneca Family of Agencies, which provides mental health and other services for children in California. According to Berrick, overuse of medication has been a problem for decades, often because better alternatives simply weren’t available. “Medication is available right now on demand, and other services are not,” he said. “When you don’t have a choice, you rely on what you have.”

Under the reforms, there would be better monitoring of children on medication and closer scrutiny of physicians to identify doctors who rely most heavily on medication. The bill also calls for stricter oversight of group homes to determine if psychotropic medications are used to control children’s behavior. “Drugging and sedating children should never be considered the primary option in lieu of counseling, therapy and appropriate treatment,” said the bill’s author, Sen. Jim Beall, D-San Jose.

In addition, social workers and caregivers in California would receive training in the risks, benefits and side effects of psychiatric medications. A mix of state and federal dollars would establish a structure to provide second medical opinions.

Beyond reining in prescribing outliers, the legislation also places a new emphasis on defining what comprises appropriate care for vulnerable youth. “It’s no longer a drugs-only approach,” explained Johnson, who said the legislation would require that children who are being given powerful medications also receive other services.

“We’re saying, you have to do something else — either first or at the same time — to really help a troubled child,” said Johnson. “Swallowing a pill doesn’t help with grief or trauma. It may contain symptoms, but it doesn’t help you move forward and be functional in life.”

In legislative hearings, former foster youth testified about negative side effects from taking psychotropic medications, sometimes unwillingly. And they described how alternatives to drug therapy often led to better outcomes.

For Tisha Ortiz, 22, help finally came in the form of a therapeutic behavioral services worker who took a genuine interest in her. “I felt loved by her, that she actually cared,” said Ortiz.

Ortiz had a chaotic childhood filled with emotional and sexual abuse. While she lived in various group homes, she often lashed out at adults and resorted to self-harm when her emotions got the better of her. For years she lived with flashbacks to traumatic events, which her caregivers and social workers misinterpreted. “They considered the flashbacks as hearing voices, so I got put on psychotropic meds for that, when I wasn’t hearing voices at all.”

On medication, Ortiz gained weight and found it hard to stay awake, yet she continued to feel abandoned and depressed. “I just felt sedated, and I wasn’t really dealing with the problems,” she said.

According to Ortiz, she did not begin to get better until she was connected with a behavioral services worker who encouraged her to talk about her past. “She helped me understand that what I was feeling was because of the situations I went through and not because there’s all these things wrong with me.”

Since then, Ortiz has had other therapists who she felt really listened to her, whom she still occasionally calls if she’s had a bad day. But the self-harm has stopped, and she’s tapering off the one medication that she still takes. Ortiz says it was human interaction, not drugs, that helped her. “Having that love was one of the first steps that put me on the road to getting better.”

There are a lot of good evidence-based treatments that work, said Shadi Houshyar, vice president for child welfare policy at First Focus, a national children’s advocacy organization. “States are just struggling with finding the providers, the resources and the dollars to pay for these interventions,” she said.

Some states resort to Medicaid waivers or use their child welfare general funds to match Medicaid dollars, but that’s not enough, Houshyar said. That’s why First Focus and other advocacy groups have been big proponents of a White House program aimed at curbing the misuse of psychiatric medication in foster care.

The Obama administration has called on states to advance alternative treatments in their child welfare systems. In his 2015 and 2016 budget proposals, President Obama unveiled a two-pronged plan allocating $750 million in grant dollars and incentive payments to address the overprescribing of psychotropics.

The demonstration project would bring child welfare and Medicaid agencies together to provide more coordinated services, including behavioral therapies, to foster kids with a history of trauma or mental health problems. “If we really want to solve this problem, we have to make the alternative interventions available at the same level at which medication is available,” said Berrick. “It’s really a question of access. When that happens, people will make the right decision.”

Elaine Korry writes about healthcare and social policy from the San Francisco Bay area. This story was produced by Youth Today, the national news source for youth-service professionals, including child welfare and juvenile justice, youth development and out-of-school-time programming.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.

In her third year of medical school, Karen Duong found herself on the other side of Texas. She had driven 12 hours north from where she grew up on the Gulf Coast to a panhandle town called Hereford.

“Hereford is known for being the beef capital of the world,” she says, laughing. “There’s definitely more cows than people out there.”

It’s even named after a breed of cattle. Out here, there aren’t many people who provide mental health care. In fact, there aren’t any psychiatrists. That’s the reason Duong went there – she’s studying psychiatry as a medical student
at the University of North Texas Health Science Center. This assignment showed her just how severe the state’s mental health care shortage is.

“You have a patient that comes in and they need immediate care or something more acute, and then you tell them that the soonest they can get in for an appointment is six months from now,” Duong says. “It’s not really what we want to tell our patients.”

Hereford is one of many areas in Texas lacking adequate access to mental health care.

Of the 254 counties in Texas, 185 have no psychiatrist, according to Travis Singleton, who tracks physician shortages for Merritt Hawkins, a Texas-based consulting firm. “That’s almost 3.2 million [people],” he says.

The shortage goes beyond Texas. In the past year, Singleton’s firm has been asked to recruit more psychiatrists nationwide than ever before.

“While we knew the demand was high, I don’t think anyone expected it to that extent,” he says.

Supply issues have crept up on psychiatry, Travis says. “You have less and less residents wanting to go in this specialty in general, and then you have those that actually do practice medicine not necessarily in the most optimal settings for us.”

So how do you persuade students to become psychiatrists, social workers and psychologists, and then be willing to work in rural areas?

Republican state Sen. Charles Schwertner is trying cash. He sponsored a law that, starting in 2016, will help around 100 medical health professionals repay loans if they go to work in underserved areas. Schwertner says the investment will pay off.

“Where we don’t have those services for mental health patients, they wind up cycling back through our jails and our emergency rooms,” he says.

There are a number of loan repayment programs for students focused on mental health across the country. They’re “at least somewhat successful,” says Sita Diehl, director of state policy and advocacy with the National Alliance on Mental Illness.

But she doesn’t think they go far enough.

“The most successful strategies are to find young people within the rural community. They know the community, they have an investment in the community,” Diehl says. “Otherwise the turnover rates in these loan repayment programs are pretty high.”

For medical student Duong, it’s also important to address the stigma of seeking and treating mental health care.

“Even I have some family members who aren’t supportive of me going into psychiatry,” she says. “There are people out there who don’t think mental illness should be considered a diagnosis.”

But Duong says she’s now committed to working in a rural Texas town, despite some sacrifices.

“It doesn’t compare,” she says, “having all these luxuries in a city versus being able to go out there and really make a difference in your patients’ lives.”

This motivation is exactly what Schwertner is looking to spark with the state’s loan repayment program.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News.

Copyright 2015 KERA Unlimited. To see more, visit http://www.kera.org/.

Earlier this month, 49-year-old Joseph Murphy died at Juneau’s prison 12 hours after being booked on noncriminal charges.

Among other things, Murphy was an Iraq War veteran. His squad commander says it changed him forever. I spoke to some of the men Murphy served with.

Mike Mercer joined the Alaska Army National Guard in the summer of 2001.

“That’s where I met Murphy,” he says.

Mercer and Spc. Joseph Murphy both lived in Juneau.

“Murphy taught me how to march. Murphy taught me all the really basic stuff – how to shine my boots, how to stand at the position of attention, the position of parade rest,” Mercer says.

One weekend each month, they saw each other for training. Then in 2005, Mercer and Murphy and many others in the Alaska National Guard were sent to war for one year.

“When we went to Iraq, we all got different little nicknames and Murphy got Eskimo Joe,” Mercer says.

Murphy’s wife of many years could not be reached for comment. According to a paid obituary in the Juneau Empire, Murphy was born in Anchorage, but grew up in Emmonak.

Mercer and Murphy were both gunners, each conducting patrols from a gun turret of a Humvee.

“Murph just worked harder than everybody else it seemed like, just because he was always giving as much as he could give. He definitely took care of the guy to his left and to his right. If somebody needed more water, if somebody needed somebody to talk to, if somebody needed some help with anything, Murph was really supportive of people,” Mercer says.

Ed Irizarry says Murphy put his life in jeopardy looking out for others. Murphy was part of the squad Irizarry led in Iraq. During patrols, “we encountered other vehicles that were blocking roads that were suspicious. Could be a car bomb,” Irizarry says.

Irizarry recalls times when, “I was going to walk up to it and Murphy, you know, ‘No, I’ll go do it sergeant.’ He takes off running and he comes back and he says, ‘All clear.’ So what do you tell a man that has just went out there and could give his life for you? What do you tell that guy? A thank you doesn’t seem to be enough.”

Irizarry was deeply sad when he heard Murphy died, “Joe was living with a lot of demons as the rest of us are.”

He mentions a specific car bombing in Iraq, but doesn’t give details.

“He had to witness something a human should never have to see. And I think that damaged him. You take a 40-year-old man who’s never seen anything like that in his life. And he’s got such a big heart, family oriented, do anything for anyone, happy-go-lucky, and then he sees that hell. That changes a man,” Irizarry says.

Irizarry lives in Ketchikan and retired from the military after 22 years, including time in four combat zones.

He says Murphy experienced post-traumatic stress disorder and sought help. More than 40 percent of National Guard members who served in Iraq or Afghanistan have symptoms of PTSD, according to the National Center for PTSD.

Murphy’s obituary says he also battled depression and struggled with substance abuse. But Irizarry wants Murphy to be remembered as the funny, kind man he was.

“You could crack a joke on him or tease him about something and he would laugh so hard at himself and just never got upset. He’d just kind of shake his head, ‘OK, you got me.’ So he was just like a young kid and you couldn’t help but fall in love with him,” Irizarry says.

Mike Mercer also experienced symptoms of PTSD, although he’s never been clinically diagnosed. Before Iraq, Mercer says he was a people person. When he returned to Juneau in 2006, he was apprehensive of large groups. He had bad dreams. He couldn’t watch July Fourth fireworks and had trouble driving close to other cars.

“All of us have had problems here and there. Some stuff fades, some stuff doesn’t,” Mercer says.

The last time Mercer saw Murphy was about five years ago at Fred Meyer.

“It doesn’t matter how long we go without seeing each other. Could’ve been another 10 years before I saw Murph, we’d still embrace each other as if we’d just seen other yesterday,” he says.

When you serve in war together, Mercer says, you’re brothers.

“It’s just a bond. You can’t break that. Time ain’t going to break it. I guess even the death of one of your brothers can’t break that either. Murph will always be my brother,” Mercer says.

Murphy was in the emergency room of Bartlett Regional Hospital the night of Aug. 13. Juneau Police transferred him to Lemon Creek Correctional Center on a 12-hour protective hold. A police spokesman says alcohol was a factor. Murphy died in a holding cell the next morning of an apparent heart attack.

The obituary says Murphy will be buried in Emmonak.

An unprecedented, class action lawsuit brought against one Southern California school district and its top officials could have a big impact on schools across the country.

On Thursday in Los Angeles, a U.S. District Court judge will preside over the first hearing in the suit against the Compton Unified School District. To understand the complaint, you need to understand Compton.

The city, located just south of LA, has long had a violent reputation. Last year, its murder rate was more than five times the national average. Now, a handful of students say they’ve been traumatized by life in Compton and that the schools there have failed to give them the help they deserve.

The complaint is a terrifying read — of kids coping with physical and sexual abuse, addicted parents, homelessness and a constant fear of violence.

One of the plaintiffs, listed as 15-year-old Phillip W., says he witnessed his first murder when he was 8.

“Somebody got shot in the back of the head with a shotgun,” the boy explains in a video on a website dedicated to the case. “And they threw him over the rail, and he was just sitting there bleeding, blood all down the sewer line. It was a horrifying sight.”

The complaint says Phillip has witnessed more than 20 shootings and, in 2014, was hit in the knee by a bullet.

What’s this have to do with Compton’s schools?

Susan Ko of the National Center for Child Traumatic Stress says exposure to violence can have a profound effect on the brain’s ability to learn.

“That impacts concentration, the ability to just listen to what the teacher is saying, to understand what you’re reading, to remember something that you learned or what the teacher just said,” Ko says.

Not only that, many traumatized students live in a state of constant alarm. Innocent interactions like a bump in the hallway or a request from a teacher can stir anger and bad behavior.

The lawsuit alleges that, in Compton, the schools’ reaction to traumatized students was too often punishment — not help.

“They were repeatedly either sent to another school, expelled or suspended — and this went back to kindergarten,” says Marleen Wong, who teaches at the USC School of Social Work and has spent decades studying kids and trauma. “I think we’re really doing a terrible disservice to these children.”

The suit argues that trauma is a disability and that schools are required — by federal law — to make accommodations for traumatized students, not expel them. The plaintiffs want Compton Unified to provide teacher training, mental health support for students and to use conflict-mediation before resorting to suspension.

“That’s a very strong mandate, and it needs to be funded,” says the district’s attorney, David Huff. He argues the suit uses too broad a definition of disability and sends the wrong message to kids living in other struggling neighborhoods.

“A sweeping declaration would effectively tell these children that they have now been labeled as having a physical or mental handicap under federal law.”

Compton Unified has asked the judge to dismiss the case.

This idea — of treating trauma in children as a disability — is new, though the problem is not, says Ko. “Twenty-five percent of kids will have experienced a traumatic event before the age of 16.”

Not all of those children will struggle in school. But many will — and not just in Compton, where students returned to class this week bringing with them the stories of summer, good and bad.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.