Carl C. Bell, MD

The recent suicide of a 23-year-old black man who was a leading member of Ohio’s Black Lives Matter movement raises concerns about African American suicidal behavior.

Anyone delving into the issue of African American suicide finds a great deal of confusion and ambiguity. On the one hand, the national statistics reveal that African American women have the lowest rates of suicide of anyone in the United States at 2/100,000 – about half that of white women. Similarly, African American males historically have had half the suicide rates of white men. As to the question of what accounts for this disparity – no one knows.

Some have argued that spirituality protects African Americans from such self-destruction, but the solid scientific evidence for this is watery. When I have asked black women about the reason for their low rates of suicide, their responses have been “I don’t have time to kill myself,” and “I have too many people to take care of to kill myself,” but these reactions are anecdotal at best.

Another consideration is the fact that suicide is the third leading cause of death in young people, according to data from the Centers for Disease Control and Prevention. However, the actual overall rates of suicide are 11/100,000, and in young adults, it may be as high as 20/100,000, making completed suicide a very rare event. How can someone identify 20 people in a population of 100,000? And when we look at homicide rates, we find that they have never exceeded suicide rates.

These two considerations have made the scientific study of suicide prevention extraordinarily difficult. Of course, any study of suicide in the African American community would have to factor in depression, schizophrenia, traumatic brain injuries, and posttraumatic stress disorders, as these disorders are most certainly associated with a higher risk of suicide. The same holds true for alcohol and drug addiction, as well as anxiety disorders, but even here, the rates are fairly low.

To further complicate matters, there is the association of adverse childhood experiences with suicide attempts. However, again, suicides are a very rare phenomenon, making drawing any statistical conclusions about what causes or prevents suicide impossible. It has been suggested that the never-ending microinsults and discrimination that African Americans experience slowly but surely erode vital self-esteem, resulting in a fatalistic demoralization and ending in self-destruction.

Someone taking his own life is a very complex conundrum, and when that lens gets focused on African American suicides, the challenge is all the more difficult because of the dearth of research on African Americans. Perhaps if there were more research, by now someone would have answered the question of why African American women have the lowest rates of suicide, compared with other demographic groups in our nation.

The long and short of it is, whenever there is a suicide that is highly publicized, everyone comes out of the woodwork with various theories and explanations, but we cannot afford to let the media shape our science. We need serious inquiry into mental health issues of people of color. Behavior is multidetermined. With serious investigation, we may be able to identify some factors that have a 30%-40% influence on a behavioral outcome, and research may be able to understand how to influence those factors and change them so their impact is reduced in shaping behavioral outcomes. But for now, we simply do not know enough about the rare event of suicide in African Americans to speculate about why individuals took their lives or how to prevent such tragedies. Clearly, whenever we hear of a suicide of a gifted African American youth like MarShawn M. McCarrel II, who did so much for so many, we wonder what his motivation may have been. He certainly had so much more to contribute to life.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

The recent suicide of a 23-year-old black man who was a leading member of Ohio’s Black Lives Matter movement raises concerns about African American suicidal behavior.

Anyone delving into the issue of African American suicide finds a great deal of confusion and ambiguity. On the one hand, the national statistics reveal that African American women have the lowest rates of suicide of anyone in the United States at 2/100,000 – about half that of white women. Similarly, African American males historically have had half the suicide rates of white men. As to the question of what accounts for this disparity – no one knows.

Some have argued that spirituality protects African Americans from such self-destruction, but the solid scientific evidence for this is watery. When I have asked black women about the reason for their low rates of suicide, their responses have been “I don’t have time to kill myself,” and “I have too many people to take care of to kill myself,” but these reactions are anecdotal at best.

Another consideration is the fact that suicide is the third leading cause of death in young people, according to data from the Centers for Disease Control and Prevention. However, the actual overall rates of suicide are 11/100,000, and in young adults, it may be as high as 20/100,000, making completed suicide a very rare event. How can someone identify 20 people in a population of 100,000? And when we look at homicide rates, we find that they have never exceeded suicide rates.

These two considerations have made the scientific study of suicide prevention extraordinarily difficult. Of course, any study of suicide in the African American community would have to factor in depression, schizophrenia, traumatic brain injuries, and posttraumatic stress disorders, as these disorders are most certainly associated with a higher risk of suicide. The same holds true for alcohol and drug addiction, as well as anxiety disorders, but even here, the rates are fairly low.

To further complicate matters, there is the association of adverse childhood experiences with suicide attempts. However, again, suicides are a very rare phenomenon, making drawing any statistical conclusions about what causes or prevents suicide impossible. It has been suggested that the never-ending microinsults and discrimination that African Americans experience slowly but surely erode vital self-esteem, resulting in a fatalistic demoralization and ending in self-destruction.

Someone taking his own life is a very complex conundrum, and when that lens gets focused on African American suicides, the challenge is all the more difficult because of the dearth of research on African Americans. Perhaps if there were more research, by now someone would have answered the question of why African American women have the lowest rates of suicide, compared with other demographic groups in our nation.

The long and short of it is, whenever there is a suicide that is highly publicized, everyone comes out of the woodwork with various theories and explanations, but we cannot afford to let the media shape our science. We need serious inquiry into mental health issues of people of color. Behavior is multidetermined. With serious investigation, we may be able to identify some factors that have a 30%-40% influence on a behavioral outcome, and research may be able to understand how to influence those factors and change them so their impact is reduced in shaping behavioral outcomes. But for now, we simply do not know enough about the rare event of suicide in African Americans to speculate about why individuals took their lives or how to prevent such tragedies. Clearly, whenever we hear of a suicide of a gifted African American youth like MarShawn M. McCarrel II, who did so much for so many, we wonder what his motivation may have been. He certainly had so much more to contribute to life.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

The recent suicide of a 23-year-old black man who was a leading member of Ohio’s Black Lives Matter movement raises concerns about African American suicidal behavior.

Anyone delving into the issue of African American suicide finds a great deal of confusion and ambiguity. On the one hand, the national statistics reveal that African American women have the lowest rates of suicide of anyone in the United States at 2/100,000 – about half that of white women. Similarly, African American males historically have had half the suicide rates of white men. As to the question of what accounts for this disparity – no one knows.

Some have argued that spirituality protects African Americans from such self-destruction, but the solid scientific evidence for this is watery. When I have asked black women about the reason for their low rates of suicide, their responses have been “I don’t have time to kill myself,” and “I have too many people to take care of to kill myself,” but these reactions are anecdotal at best.

Another consideration is the fact that suicide is the third leading cause of death in young people, according to data from the Centers for Disease Control and Prevention. However, the actual overall rates of suicide are 11/100,000, and in young adults, it may be as high as 20/100,000, making completed suicide a very rare event. How can someone identify 20 people in a population of 100,000? And when we look at homicide rates, we find that they have never exceeded suicide rates.

These two considerations have made the scientific study of suicide prevention extraordinarily difficult. Of course, any study of suicide in the African American community would have to factor in depression, schizophrenia, traumatic brain injuries, and posttraumatic stress disorders, as these disorders are most certainly associated with a higher risk of suicide. The same holds true for alcohol and drug addiction, as well as anxiety disorders, but even here, the rates are fairly low.

To further complicate matters, there is the association of adverse childhood experiences with suicide attempts. However, again, suicides are a very rare phenomenon, making drawing any statistical conclusions about what causes or prevents suicide impossible. It has been suggested that the never-ending microinsults and discrimination that African Americans experience slowly but surely erode vital self-esteem, resulting in a fatalistic demoralization and ending in self-destruction.

Someone taking his own life is a very complex conundrum, and when that lens gets focused on African American suicides, the challenge is all the more difficult because of the dearth of research on African Americans. Perhaps if there were more research, by now someone would have answered the question of why African American women have the lowest rates of suicide, compared with other demographic groups in our nation.

The long and short of it is, whenever there is a suicide that is highly publicized, everyone comes out of the woodwork with various theories and explanations, but we cannot afford to let the media shape our science. We need serious inquiry into mental health issues of people of color. Behavior is multidetermined. With serious investigation, we may be able to identify some factors that have a 30%-40% influence on a behavioral outcome, and research may be able to understand how to influence those factors and change them so their impact is reduced in shaping behavioral outcomes. But for now, we simply do not know enough about the rare event of suicide in African Americans to speculate about why individuals took their lives or how to prevent such tragedies. Clearly, whenever we hear of a suicide of a gifted African American youth like MarShawn M. McCarrel II, who did so much for so many, we wonder what his motivation may have been. He certainly had so much more to contribute to life.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

After the Newtown, Conn., tragedy in December 2012, I wrote about my understanding of “suicide preceded by mass murder” and my supposition that an element of contagion was involved with the dynamics of such events.

I highlighted David Phillips’ seminal research in the area of “contagion suicides,” and noted that when an individual commits suicide and the media give that suicide a lot of coverage, shortly afterward, “copycat” or “contagion” suicides seem to occur.

The association is so strong that the American Foundation for Suicide Prevention, the American Association of Suicidology, and the Annenberg Public Policy Center have provided “Reporting on Suicide: Recommendations for the Media.” These guidelines suggest that the media not give a great deal of attention to the phenomenon of suicide, and they begin with the assertion that “suicide contagion is real.”

The problem is that suicide preceded by mass murder and such events are so “newsworthy” that it is difficult for the media to avoid reporting on them. Researchers at Arizona State University’s Simon A. Levin Mathematical, Computational and Modeling Sciences Center, Tempe, and Northeastern Illinois University, Chicago, have done probability studies indicating that the patterns of many such events are bunched in time rather than occurring randomly (indicating contagion). Specifically, the researchers found “significant evidence that mass killings involving firearms are incented by similar events in the immediate past” (PLOS One. 2015 Jul 2. doi: 10.1371/journal.pone.0117259). “We also find significant evidence of contagion in school shootings, for an incident is contagious for an average of 13 days, and incites an average of at least 0.22 new incidents (P = .0001),” they noted.

The researchers also identified patterns among mass shootings in the United States involving firearms and school shootings: “Mass killings involving firearms occur approximately every 2 weeks in the United States, while school shootings occur on average monthly,” they wrote.

They used the same methodology that Phillips used in his studies, but the more recent research had to use a wider data base (Phillips used local newspapers; pre-Internet, most news was local), and relied on USA Today mass killings data and Brady Campaign data as the media coverage of these events is widespread and ubiquitous. The authors’ study shows that 20%-30% of the suicides preceded by mass murder stem from contagion.

Still, those of us who are in the business of prevention and treatment must wonder who is susceptible.

One empirically based observation about school shootings has come to my attention, thanks to Jody Allen Crowe, a lifelong educator who has studied many of the school shootings and written a book on the topic called, “The Fatal Link” (Denver: Outskirts Press, 2008).

In this book, he addresses a simple question: “What would cause a person to have such poor judgment as to go into a school, kill a bunch of innocent people, and then often kill themselves?” Mr. Crowe’s answer is simple: “fetal alcohol exposure.” He has been an educator on several Native American reservation schools and has seen firsthand the classical dysfunctional emotional and behavioral patterns of children who were exposed to alcohol as fetuses – poor social skills and affect regulation, intellectual challenges, difficulty learning from experience, and so on.

He has taken the time to gather information about the 69 school shooters from 1966 to 2008. He was able to cull enough information on 66% of the shooters to determine that they probably had prenatal exposure to alcohol. In 25%, there was not enough information, and 9% did not have the five factors used to determine probable exposure, according to Mr. Crowe, founder and president of a nonprofit organization called Healthy Brains for Children.

My question is: When is America’s media going to learn that inundating American citizens with stories of “suicide preceded by mass murder” leads to more casualties? Such stories are just not healthy. Of course we want our First Amendment freedoms, but I doubt if any of us want violent ideas being planted in those most vulnerable to being influenced to perpetrate a school shooting.

The difficulty is getting the media’s frontal lobes awake enough to stop being imprisoned by their amygdalae and their urge to follow the maximum, ‘If it bleeds, it leads,” and to help them understand, based on research, that they are promoting 20%-30% of the school shootings – maybe even more.

If Jody Allen Crowe is right, and, based on my own clinical experience and research, I believe he is, the medical community needs to do something about the root cause of school shootings – fetal alcohol exposure. As former Surgeon General David Satcher always reminds us, “There is a terrifying gap between what we do know and how we act.”

Dr. Bell is staff psychiatrist at the Jackson Park Hospital Family Medicine Center and former president/CEO of the Community Mental Health Council, both in Chicago. He is former director of the Institute for Juvenile Research and former professor of psychiatry and public health at the University of Illinois at Chicago.

After the Newtown, Conn., tragedy in December 2012, I wrote about my understanding of “suicide preceded by mass murder” and my supposition that an element of contagion was involved with the dynamics of such events.

I highlighted David Phillips’ seminal research in the area of “contagion suicides,” and noted that when an individual commits suicide and the media give that suicide a lot of coverage, shortly afterward, “copycat” or “contagion” suicides seem to occur.

The association is so strong that the American Foundation for Suicide Prevention, the American Association of Suicidology, and the Annenberg Public Policy Center have provided “Reporting on Suicide: Recommendations for the Media.” These guidelines suggest that the media not give a great deal of attention to the phenomenon of suicide, and they begin with the assertion that “suicide contagion is real.”

The problem is that suicide preceded by mass murder and such events are so “newsworthy” that it is difficult for the media to avoid reporting on them. Researchers at Arizona State University’s Simon A. Levin Mathematical, Computational and Modeling Sciences Center, Tempe, and Northeastern Illinois University, Chicago, have done probability studies indicating that the patterns of many such events are bunched in time rather than occurring randomly (indicating contagion). Specifically, the researchers found “significant evidence that mass killings involving firearms are incented by similar events in the immediate past” (PLOS One. 2015 Jul 2. doi: 10.1371/journal.pone.0117259). “We also find significant evidence of contagion in school shootings, for an incident is contagious for an average of 13 days, and incites an average of at least 0.22 new incidents (P = .0001),” they noted.

The researchers also identified patterns among mass shootings in the United States involving firearms and school shootings: “Mass killings involving firearms occur approximately every 2 weeks in the United States, while school shootings occur on average monthly,” they wrote.

They used the same methodology that Phillips used in his studies, but the more recent research had to use a wider data base (Phillips used local newspapers; pre-Internet, most news was local), and relied on USA Today mass killings data and Brady Campaign data as the media coverage of these events is widespread and ubiquitous. The authors’ study shows that 20%-30% of the suicides preceded by mass murder stem from contagion.

Still, those of us who are in the business of prevention and treatment must wonder who is susceptible.

One empirically based observation about school shootings has come to my attention, thanks to Jody Allen Crowe, a lifelong educator who has studied many of the school shootings and written a book on the topic called, “The Fatal Link” (Denver: Outskirts Press, 2008).

In this book, he addresses a simple question: “What would cause a person to have such poor judgment as to go into a school, kill a bunch of innocent people, and then often kill themselves?” Mr. Crowe’s answer is simple: “fetal alcohol exposure.” He has been an educator on several Native American reservation schools and has seen firsthand the classical dysfunctional emotional and behavioral patterns of children who were exposed to alcohol as fetuses – poor social skills and affect regulation, intellectual challenges, difficulty learning from experience, and so on.

He has taken the time to gather information about the 69 school shooters from 1966 to 2008. He was able to cull enough information on 66% of the shooters to determine that they probably had prenatal exposure to alcohol. In 25%, there was not enough information, and 9% did not have the five factors used to determine probable exposure, according to Mr. Crowe, founder and president of a nonprofit organization called Healthy Brains for Children.

My question is: When is America’s media going to learn that inundating American citizens with stories of “suicide preceded by mass murder” leads to more casualties? Such stories are just not healthy. Of course we want our First Amendment freedoms, but I doubt if any of us want violent ideas being planted in those most vulnerable to being influenced to perpetrate a school shooting.

The difficulty is getting the media’s frontal lobes awake enough to stop being imprisoned by their amygdalae and their urge to follow the maximum, ‘If it bleeds, it leads,” and to help them understand, based on research, that they are promoting 20%-30% of the school shootings – maybe even more.

If Jody Allen Crowe is right, and, based on my own clinical experience and research, I believe he is, the medical community needs to do something about the root cause of school shootings – fetal alcohol exposure. As former Surgeon General David Satcher always reminds us, “There is a terrifying gap between what we do know and how we act.”

Dr. Bell is staff psychiatrist at the Jackson Park Hospital Family Medicine Center and former president/CEO of the Community Mental Health Council, both in Chicago. He is former director of the Institute for Juvenile Research and former professor of psychiatry and public health at the University of Illinois at Chicago.

After the Newtown, Conn., tragedy in December 2012, I wrote about my understanding of “suicide preceded by mass murder” and my supposition that an element of contagion was involved with the dynamics of such events.

I highlighted David Phillips’ seminal research in the area of “contagion suicides,” and noted that when an individual commits suicide and the media give that suicide a lot of coverage, shortly afterward, “copycat” or “contagion” suicides seem to occur.

The association is so strong that the American Foundation for Suicide Prevention, the American Association of Suicidology, and the Annenberg Public Policy Center have provided “Reporting on Suicide: Recommendations for the Media.” These guidelines suggest that the media not give a great deal of attention to the phenomenon of suicide, and they begin with the assertion that “suicide contagion is real.”

The problem is that suicide preceded by mass murder and such events are so “newsworthy” that it is difficult for the media to avoid reporting on them. Researchers at Arizona State University’s Simon A. Levin Mathematical, Computational and Modeling Sciences Center, Tempe, and Northeastern Illinois University, Chicago, have done probability studies indicating that the patterns of many such events are bunched in time rather than occurring randomly (indicating contagion). Specifically, the researchers found “significant evidence that mass killings involving firearms are incented by similar events in the immediate past” (PLOS One. 2015 Jul 2. doi: 10.1371/journal.pone.0117259). “We also find significant evidence of contagion in school shootings, for an incident is contagious for an average of 13 days, and incites an average of at least 0.22 new incidents (P = .0001),” they noted.

The researchers also identified patterns among mass shootings in the United States involving firearms and school shootings: “Mass killings involving firearms occur approximately every 2 weeks in the United States, while school shootings occur on average monthly,” they wrote.

They used the same methodology that Phillips used in his studies, but the more recent research had to use a wider data base (Phillips used local newspapers; pre-Internet, most news was local), and relied on USA Today mass killings data and Brady Campaign data as the media coverage of these events is widespread and ubiquitous. The authors’ study shows that 20%-30% of the suicides preceded by mass murder stem from contagion.

Still, those of us who are in the business of prevention and treatment must wonder who is susceptible.

One empirically based observation about school shootings has come to my attention, thanks to Jody Allen Crowe, a lifelong educator who has studied many of the school shootings and written a book on the topic called, “The Fatal Link” (Denver: Outskirts Press, 2008).

In this book, he addresses a simple question: “What would cause a person to have such poor judgment as to go into a school, kill a bunch of innocent people, and then often kill themselves?” Mr. Crowe’s answer is simple: “fetal alcohol exposure.” He has been an educator on several Native American reservation schools and has seen firsthand the classical dysfunctional emotional and behavioral patterns of children who were exposed to alcohol as fetuses – poor social skills and affect regulation, intellectual challenges, difficulty learning from experience, and so on.

He has taken the time to gather information about the 69 school shooters from 1966 to 2008. He was able to cull enough information on 66% of the shooters to determine that they probably had prenatal exposure to alcohol. In 25%, there was not enough information, and 9% did not have the five factors used to determine probable exposure, according to Mr. Crowe, founder and president of a nonprofit organization called Healthy Brains for Children.

My question is: When is America’s media going to learn that inundating American citizens with stories of “suicide preceded by mass murder” leads to more casualties? Such stories are just not healthy. Of course we want our First Amendment freedoms, but I doubt if any of us want violent ideas being planted in those most vulnerable to being influenced to perpetrate a school shooting.

The difficulty is getting the media’s frontal lobes awake enough to stop being imprisoned by their amygdalae and their urge to follow the maximum, ‘If it bleeds, it leads,” and to help them understand, based on research, that they are promoting 20%-30% of the school shootings – maybe even more.

If Jody Allen Crowe is right, and, based on my own clinical experience and research, I believe he is, the medical community needs to do something about the root cause of school shootings – fetal alcohol exposure. As former Surgeon General David Satcher always reminds us, “There is a terrifying gap between what we do know and how we act.”

Dr. Bell is staff psychiatrist at the Jackson Park Hospital Family Medicine Center and former president/CEO of the Community Mental Health Council, both in Chicago. He is former director of the Institute for Juvenile Research and former professor of psychiatry and public health at the University of Illinois at Chicago.

Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.

Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.

Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.

The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.

A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.

As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.

Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.

Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.

Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.

Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.

The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.

A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.

As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.

Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.

Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.

Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.

Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.

The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.

A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.

As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.

Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.

Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

Fetal alcohol spectrum disorders are a vibrant area of development and research. Awareness about this preventable group of conditions appears to be growing.

In fact, the Centers for Disease Control and Prevention has released an app that emphasizes how to recognize, prevent, and treat fetal alcohol spectrum disorders. Earlier rates of fetal alcohol syndrome were estimated at 1/1,000, but FASD is estimated to occur at rates of 1/100. However, as I will illustrate below, the rates of FASD are even higher – much higher among some populations than previously thought.

The DSM-5 included in its appendix the diagnostic category of neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE), which theoretically should help psychiatrists identify FASD. Of course, the DSM-5 also includes an official diagnosis of disruptive mood dysregulation disorder (DMDD), and for the life of me, I have a difficult time differentiating between the two clinically except that children and adults with ND-PAE, in contrast to patients with DMDD who are described as persistently irritable or angry most of the day, can be very amicable, naive, and overly friendly between outbursts. The other difference is that ND-PAE needs a history of the mother’s having more than minimal exposure to alcohol during gestation, including prior to pregnancy recognition, and DMDD does not have this criteria, although it may be present. And, lastly DMDD is official and ND-PAE not.

Last year, Philip A. May, Ph.D., and his associates published an important paper, “Prevalence and Characteristics of Fetal Alcohol Spectrum Disorders” (Pediatrics 2014 [doi.10.1542/peds.2013-3319]). The authors looked at a representative Midwestern U.S. community with a population base of 160,000, 87% of which were white. The per-capita income of the population was $28,000, the median household income was $51,800, and 11% were below the poverty line.

Dr. May and his associates examined 70.5% (1,433 of 2,033) of all first-graders. Using one method of prevalence estimation, they found that 28.6/1,000 had FASD. Using a second method of prevalence estimation calculated from cases of FASD, they found an FASD rate of 82/1,000. The take-home message is, regardless of the academic fine points of how prevalence is estimated, these prevalence rates are much higher than previously reported.

In a second paper by Dr. Ira J. Chasnoff and his associates – “Misdiagnosis and Missed Diagnosis in Foster Care and Adopted Children with Prenatal Alcohol Exposure” – also published in Pediatrics, the rates of FASD in foster care and adopted youth were estimated to be even higher.

This study looked at 547 youth (50.6% African American, 1.3% Asian, 32.2% white, 0.7% Native American, 12.2% biracial, and 3% other/unknown) referred for severe behavioral disorders. The researchers found that 28.5% of these youth had FASD, 86.5% of the youth had never been diagnosed or were misdiagnosed, and 26.4% of these youth were misdiagnosed as having ADHD (Pediatrics 2014 [doi:10.1542/peds.2014-2171]).

Radhika L. Chimata and I published the third paper of significance online in Psychiatric Services. This paper, which is also slated for publication in print, focused on our work in a family medicine clinic on Chicago’s South Side, serving a population of 143,000. We looked at 611 patients (96% African American with a median household income of $33,809 – only 21 were youth, the rest were adults) and found that 297 (49%) of the adults and youth had neurodevelopmental disorders with 237 (39%) having clinical profiles consistent with neurobehavioral disorders associated with prenatal alcohol exposure. Thus, this clinic population has a rate of 388/1,000.

Considering emerging research that suggests that this acquired biological disorder is being driven by the social determinants of health, for example, some low-income African Americans are living not only in food deserts but food swamps (where the liquid is alcohol; consider the plethora of liquor stores in low-income African American communities), we must recognize that FASD can be prevented prenatally and possibly improved postnatally by increasing the amount of choline in the diet. This is a potential prevention intervention issue that we cannot afford to overlook if psychiatry is going to maintain its relevance in the 21st century.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

Fetal alcohol spectrum disorders are a vibrant area of development and research. Awareness about this preventable group of conditions appears to be growing.

In fact, the Centers for Disease Control and Prevention has released an app that emphasizes how to recognize, prevent, and treat fetal alcohol spectrum disorders. Earlier rates of fetal alcohol syndrome were estimated at 1/1,000, but FASD is estimated to occur at rates of 1/100. However, as I will illustrate below, the rates of FASD are even higher – much higher among some populations than previously thought.

The DSM-5 included in its appendix the diagnostic category of neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE), which theoretically should help psychiatrists identify FASD. Of course, the DSM-5 also includes an official diagnosis of disruptive mood dysregulation disorder (DMDD), and for the life of me, I have a difficult time differentiating between the two clinically except that children and adults with ND-PAE, in contrast to patients with DMDD who are described as persistently irritable or angry most of the day, can be very amicable, naive, and overly friendly between outbursts. The other difference is that ND-PAE needs a history of the mother’s having more than minimal exposure to alcohol during gestation, including prior to pregnancy recognition, and DMDD does not have this criteria, although it may be present. And, lastly DMDD is official and ND-PAE not.

Last year, Philip A. May, Ph.D., and his associates published an important paper, “Prevalence and Characteristics of Fetal Alcohol Spectrum Disorders” (Pediatrics 2014 [doi.10.1542/peds.2013-3319]). The authors looked at a representative Midwestern U.S. community with a population base of 160,000, 87% of which were white. The per-capita income of the population was $28,000, the median household income was $51,800, and 11% were below the poverty line.

Dr. May and his associates examined 70.5% (1,433 of 2,033) of all first-graders. Using one method of prevalence estimation, they found that 28.6/1,000 had FASD. Using a second method of prevalence estimation calculated from cases of FASD, they found an FASD rate of 82/1,000. The take-home message is, regardless of the academic fine points of how prevalence is estimated, these prevalence rates are much higher than previously reported.

In a second paper by Dr. Ira J. Chasnoff and his associates – “Misdiagnosis and Missed Diagnosis in Foster Care and Adopted Children with Prenatal Alcohol Exposure” – also published in Pediatrics, the rates of FASD in foster care and adopted youth were estimated to be even higher.

This study looked at 547 youth (50.6% African American, 1.3% Asian, 32.2% white, 0.7% Native American, 12.2% biracial, and 3% other/unknown) referred for severe behavioral disorders. The researchers found that 28.5% of these youth had FASD, 86.5% of the youth had never been diagnosed or were misdiagnosed, and 26.4% of these youth were misdiagnosed as having ADHD (Pediatrics 2014 [doi:10.1542/peds.2014-2171]).

Radhika L. Chimata and I published the third paper of significance online in Psychiatric Services. This paper, which is also slated for publication in print, focused on our work in a family medicine clinic on Chicago’s South Side, serving a population of 143,000. We looked at 611 patients (96% African American with a median household income of $33,809 – only 21 were youth, the rest were adults) and found that 297 (49%) of the adults and youth had neurodevelopmental disorders with 237 (39%) having clinical profiles consistent with neurobehavioral disorders associated with prenatal alcohol exposure. Thus, this clinic population has a rate of 388/1,000.

Considering emerging research that suggests that this acquired biological disorder is being driven by the social determinants of health, for example, some low-income African Americans are living not only in food deserts but food swamps (where the liquid is alcohol; consider the plethora of liquor stores in low-income African American communities), we must recognize that FASD can be prevented prenatally and possibly improved postnatally by increasing the amount of choline in the diet. This is a potential prevention intervention issue that we cannot afford to overlook if psychiatry is going to maintain its relevance in the 21st century.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

Fetal alcohol spectrum disorders are a vibrant area of development and research. Awareness about this preventable group of conditions appears to be growing.

In fact, the Centers for Disease Control and Prevention has released an app that emphasizes how to recognize, prevent, and treat fetal alcohol spectrum disorders. Earlier rates of fetal alcohol syndrome were estimated at 1/1,000, but FASD is estimated to occur at rates of 1/100. However, as I will illustrate below, the rates of FASD are even higher – much higher among some populations than previously thought.

The DSM-5 included in its appendix the diagnostic category of neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE), which theoretically should help psychiatrists identify FASD. Of course, the DSM-5 also includes an official diagnosis of disruptive mood dysregulation disorder (DMDD), and for the life of me, I have a difficult time differentiating between the two clinically except that children and adults with ND-PAE, in contrast to patients with DMDD who are described as persistently irritable or angry most of the day, can be very amicable, naive, and overly friendly between outbursts. The other difference is that ND-PAE needs a history of the mother’s having more than minimal exposure to alcohol during gestation, including prior to pregnancy recognition, and DMDD does not have this criteria, although it may be present. And, lastly DMDD is official and ND-PAE not.

Last year, Philip A. May, Ph.D., and his associates published an important paper, “Prevalence and Characteristics of Fetal Alcohol Spectrum Disorders” (Pediatrics 2014 [doi.10.1542/peds.2013-3319]). The authors looked at a representative Midwestern U.S. community with a population base of 160,000, 87% of which were white. The per-capita income of the population was $28,000, the median household income was $51,800, and 11% were below the poverty line.

Dr. May and his associates examined 70.5% (1,433 of 2,033) of all first-graders. Using one method of prevalence estimation, they found that 28.6/1,000 had FASD. Using a second method of prevalence estimation calculated from cases of FASD, they found an FASD rate of 82/1,000. The take-home message is, regardless of the academic fine points of how prevalence is estimated, these prevalence rates are much higher than previously reported.

In a second paper by Dr. Ira J. Chasnoff and his associates – “Misdiagnosis and Missed Diagnosis in Foster Care and Adopted Children with Prenatal Alcohol Exposure” – also published in Pediatrics, the rates of FASD in foster care and adopted youth were estimated to be even higher.

This study looked at 547 youth (50.6% African American, 1.3% Asian, 32.2% white, 0.7% Native American, 12.2% biracial, and 3% other/unknown) referred for severe behavioral disorders. The researchers found that 28.5% of these youth had FASD, 86.5% of the youth had never been diagnosed or were misdiagnosed, and 26.4% of these youth were misdiagnosed as having ADHD (Pediatrics 2014 [doi:10.1542/peds.2014-2171]).

Radhika L. Chimata and I published the third paper of significance online in Psychiatric Services. This paper, which is also slated for publication in print, focused on our work in a family medicine clinic on Chicago’s South Side, serving a population of 143,000. We looked at 611 patients (96% African American with a median household income of $33,809 – only 21 were youth, the rest were adults) and found that 297 (49%) of the adults and youth had neurodevelopmental disorders with 237 (39%) having clinical profiles consistent with neurobehavioral disorders associated with prenatal alcohol exposure. Thus, this clinic population has a rate of 388/1,000.

Considering emerging research that suggests that this acquired biological disorder is being driven by the social determinants of health, for example, some low-income African Americans are living not only in food deserts but food swamps (where the liquid is alcohol; consider the plethora of liquor stores in low-income African American communities), we must recognize that FASD can be prevented prenatally and possibly improved postnatally by increasing the amount of choline in the diet. This is a potential prevention intervention issue that we cannot afford to overlook if psychiatry is going to maintain its relevance in the 21st century.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

The Alzheimer’s Association suggests that major neurocognitive disorder (formerly known as dementia) caused by Alzheimer’s disease is a “silent epidemic” in African Americans, noting that the prevalence among African Americans ranges from 14% to 100% higher than it is among whites.

In April 2013, the National Institute on Aging highlighted a JAMA research article that noted African Americans were more likely to have a variant of the ABCA7 gene and that this gene variant led to almost double the risk of developing Alzheimer’s disease (JAMA 2013;309:1483-92).

In addition, the Alzheimer’s Association suggests that “African Americans are seriously underrepresented in current clinical trials of potential treatment of Alzheimer’s disease, particularly in trials conducted by drug companies.” This observation echoes former U.S. Surgeon General David Satcher’s 2001 Culture, Race, and Ethnicity report, which underscored a historic dearth of research on African American mental health issues. Recently, a randomized clinical trial of citalopram in agitated patients with Alzheimer’s disease found this selective serotonin reuptake inhibitor to be efficacious in reducing agitation. However, African Americans were grossly underrepresented, comprising 15 of 94 patients in the experimental arm of this study (JAMA 2014;311:682-91).

While working on the medical/psychiatric floor at Jackson Park Hospital on Chicago’s South Side, I have watched these issues play out in real life, often delivering a harsh reality. For the past 2 years, every day, I have seen one to three elderly African American patients who had been transferred from local nursing homes with complaints of restlessness, wandering, aggression, depression, and psychosis characterized by hallucinations and delusions, which resulted in disruptive behaviors. Clinical lore suggests that such behaviors are responsible for about 50% of admissions to nursing homes and 95% of hospital admissions from such nursing homes.

Despite the known risks, too often, I see patients being prescribed first- and second-generation antipsychotics. I suppose this is because of the agitation, aggression, and psychotic symptoms. But according to the Food and Drug Administration, such prescribing is associated with premature mortality in Alzheimer’s disease. I also see a lot of benzodiazepine regimens, and this, too, is occurring despite the recent findings that benzodiazepines are associated with the etiology of Alzheimer’s disease. These practices just do not make any sense.

Recently, I saw an elderly woman with suspected Alzheimer’s disease. When I asked her the year, I saw fear and panic spread over her face as she realized that she did not remember. I decided to treat this anxiety with escitalopram 10 mg, so I gave her a dose stat (and followed up with a dose every morning).

When I checked on her the next day, after confirming that she did not remember me from the previous day (quite unusual as I wear a garish cowboy hat that my daughter gave me), I again asked what year it was. She replied with a pleasant smile: “I don’t know, and I don’t care.” She was calm and agreeable, not the frightened, panic-stricken, irritable woman I had seen the day before.

Since then, I have been repeatedly impressed with this particular SSRI in managing major neurocognitive disorder caused by Alzheimer’s disease. It brings about a night and day difference in terms of agitation and irritability, and the medical staff are amazed. And no, I do not own stock in pharmaceutical companies; escitalopram (not citalopram) is the one that the hospital formulary offers, and, in my experience, seems to have minimal side effects (agitation, blurred vision, diarrhea, insomnia, drowsiness, dry mouth, fever, frequent urination, headache, indigestion, nausea, change in appetite, sexual dysfunction, and weight change), including hepatotoxicity and hyponatremia. The other SSRIs (citalopram, duloxetine, fluoxetine, fluvoxamine, paroxetine, or sertraline) might work just as well. I would be interested to hear from other clinicians with extensive experience – for example, those who have treated hundreds of African Americans or other patients with Alzheimer’s disease – as it might take years for the research to be published and even longer before we see related data on underserved populations.

In the absence of research focused on major African American problems, we must rely on clinical experience to address these issues. I’ve been getting such positive results that I felt compelled to pass them along.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital and a member of the editorial advisory board of Clinical Psychiatry News.

The Alzheimer’s Association suggests that major neurocognitive disorder (formerly known as dementia) caused by Alzheimer’s disease is a “silent epidemic” in African Americans, noting that the prevalence among African Americans ranges from 14% to 100% higher than it is among whites.

In April 2013, the National Institute on Aging highlighted a JAMA research article that noted African Americans were more likely to have a variant of the ABCA7 gene and that this gene variant led to almost double the risk of developing Alzheimer’s disease (JAMA 2013;309:1483-92).

In addition, the Alzheimer’s Association suggests that “African Americans are seriously underrepresented in current clinical trials of potential treatment of Alzheimer’s disease, particularly in trials conducted by drug companies.” This observation echoes former U.S. Surgeon General David Satcher’s 2001 Culture, Race, and Ethnicity report, which underscored a historic dearth of research on African American mental health issues. Recently, a randomized clinical trial of citalopram in agitated patients with Alzheimer’s disease found this selective serotonin reuptake inhibitor to be efficacious in reducing agitation. However, African Americans were grossly underrepresented, comprising 15 of 94 patients in the experimental arm of this study (JAMA 2014;311:682-91).

While working on the medical/psychiatric floor at Jackson Park Hospital on Chicago’s South Side, I have watched these issues play out in real life, often delivering a harsh reality. For the past 2 years, every day, I have seen one to three elderly African American patients who had been transferred from local nursing homes with complaints of restlessness, wandering, aggression, depression, and psychosis characterized by hallucinations and delusions, which resulted in disruptive behaviors. Clinical lore suggests that such behaviors are responsible for about 50% of admissions to nursing homes and 95% of hospital admissions from such nursing homes.

Despite the known risks, too often, I see patients being prescribed first- and second-generation antipsychotics. I suppose this is because of the agitation, aggression, and psychotic symptoms. But according to the Food and Drug Administration, such prescribing is associated with premature mortality in Alzheimer’s disease. I also see a lot of benzodiazepine regimens, and this, too, is occurring despite the recent findings that benzodiazepines are associated with the etiology of Alzheimer’s disease. These practices just do not make any sense.

Recently, I saw an elderly woman with suspected Alzheimer’s disease. When I asked her the year, I saw fear and panic spread over her face as she realized that she did not remember. I decided to treat this anxiety with escitalopram 10 mg, so I gave her a dose stat (and followed up with a dose every morning).

When I checked on her the next day, after confirming that she did not remember me from the previous day (quite unusual as I wear a garish cowboy hat that my daughter gave me), I again asked what year it was. She replied with a pleasant smile: “I don’t know, and I don’t care.” She was calm and agreeable, not the frightened, panic-stricken, irritable woman I had seen the day before.

Since then, I have been repeatedly impressed with this particular SSRI in managing major neurocognitive disorder caused by Alzheimer’s disease. It brings about a night and day difference in terms of agitation and irritability, and the medical staff are amazed. And no, I do not own stock in pharmaceutical companies; escitalopram (not citalopram) is the one that the hospital formulary offers, and, in my experience, seems to have minimal side effects (agitation, blurred vision, diarrhea, insomnia, drowsiness, dry mouth, fever, frequent urination, headache, indigestion, nausea, change in appetite, sexual dysfunction, and weight change), including hepatotoxicity and hyponatremia. The other SSRIs (citalopram, duloxetine, fluoxetine, fluvoxamine, paroxetine, or sertraline) might work just as well. I would be interested to hear from other clinicians with extensive experience – for example, those who have treated hundreds of African Americans or other patients with Alzheimer’s disease – as it might take years for the research to be published and even longer before we see related data on underserved populations.

In the absence of research focused on major African American problems, we must rely on clinical experience to address these issues. I’ve been getting such positive results that I felt compelled to pass them along.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital and a member of the editorial advisory board of Clinical Psychiatry News.

The Alzheimer’s Association suggests that major neurocognitive disorder (formerly known as dementia) caused by Alzheimer’s disease is a “silent epidemic” in African Americans, noting that the prevalence among African Americans ranges from 14% to 100% higher than it is among whites.

In April 2013, the National Institute on Aging highlighted a JAMA research article that noted African Americans were more likely to have a variant of the ABCA7 gene and that this gene variant led to almost double the risk of developing Alzheimer’s disease (JAMA 2013;309:1483-92).

In addition, the Alzheimer’s Association suggests that “African Americans are seriously underrepresented in current clinical trials of potential treatment of Alzheimer’s disease, particularly in trials conducted by drug companies.” This observation echoes former U.S. Surgeon General David Satcher’s 2001 Culture, Race, and Ethnicity report, which underscored a historic dearth of research on African American mental health issues. Recently, a randomized clinical trial of citalopram in agitated patients with Alzheimer’s disease found this selective serotonin reuptake inhibitor to be efficacious in reducing agitation. However, African Americans were grossly underrepresented, comprising 15 of 94 patients in the experimental arm of this study (JAMA 2014;311:682-91).

While working on the medical/psychiatric floor at Jackson Park Hospital on Chicago’s South Side, I have watched these issues play out in real life, often delivering a harsh reality. For the past 2 years, every day, I have seen one to three elderly African American patients who had been transferred from local nursing homes with complaints of restlessness, wandering, aggression, depression, and psychosis characterized by hallucinations and delusions, which resulted in disruptive behaviors. Clinical lore suggests that such behaviors are responsible for about 50% of admissions to nursing homes and 95% of hospital admissions from such nursing homes.

Despite the known risks, too often, I see patients being prescribed first- and second-generation antipsychotics. I suppose this is because of the agitation, aggression, and psychotic symptoms. But according to the Food and Drug Administration, such prescribing is associated with premature mortality in Alzheimer’s disease. I also see a lot of benzodiazepine regimens, and this, too, is occurring despite the recent findings that benzodiazepines are associated with the etiology of Alzheimer’s disease. These practices just do not make any sense.

Recently, I saw an elderly woman with suspected Alzheimer’s disease. When I asked her the year, I saw fear and panic spread over her face as she realized that she did not remember. I decided to treat this anxiety with escitalopram 10 mg, so I gave her a dose stat (and followed up with a dose every morning).

When I checked on her the next day, after confirming that she did not remember me from the previous day (quite unusual as I wear a garish cowboy hat that my daughter gave me), I again asked what year it was. She replied with a pleasant smile: “I don’t know, and I don’t care.” She was calm and agreeable, not the frightened, panic-stricken, irritable woman I had seen the day before.

Since then, I have been repeatedly impressed with this particular SSRI in managing major neurocognitive disorder caused by Alzheimer’s disease. It brings about a night and day difference in terms of agitation and irritability, and the medical staff are amazed. And no, I do not own stock in pharmaceutical companies; escitalopram (not citalopram) is the one that the hospital formulary offers, and, in my experience, seems to have minimal side effects (agitation, blurred vision, diarrhea, insomnia, drowsiness, dry mouth, fever, frequent urination, headache, indigestion, nausea, change in appetite, sexual dysfunction, and weight change), including hepatotoxicity and hyponatremia. The other SSRIs (citalopram, duloxetine, fluoxetine, fluvoxamine, paroxetine, or sertraline) might work just as well. I would be interested to hear from other clinicians with extensive experience – for example, those who have treated hundreds of African Americans or other patients with Alzheimer’s disease – as it might take years for the research to be published and even longer before we see related data on underserved populations.

In the absence of research focused on major African American problems, we must rely on clinical experience to address these issues. I’ve been getting such positive results that I felt compelled to pass them along.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital and a member of the editorial advisory board of Clinical Psychiatry News.

When I read scientific publications on the impact of violence in the media, I am always ambivalent and skeptical. In my gut, intuitively, I believe that violence in the media must have an effect on youth. Yet, my understanding of research in this area tells me that the effect is not as significant as my intuition would have me believe.

In a recent study, Brad J. Bushman, Ph.D., of Ohio State University, Columbus, and his colleagues found that violence in films has more than doubled since 1950 (Pediatrics 2013 Nov. 11 [doi:10.1542/peds.2013-1600]). The researchers go on to suggest that the presence of guns in those films might increase the aggressive behavior of young people.

"In the wake of recent shooting sprees, legislators and the lay public are discussing possible ways to reduce youth violence," Dr. Bushman and his colleagues wrote. "What is conspicuously absent from these discussions, however, is the fact that just seeing a weapon can increase aggression, an effect dubbed the ‘weapons effect.’ "

I do not doubt the authors’ findings; for example, over the past 20 years the presence of guns in films has indeed increased dramatically. However, I think their conclusion that violent media can have harmful effects on children and youth through an increased weapons effect are misleading. Furthermore, their conclusions strike me as one-dimensional. My experience as a psychiatrist over the last 40-plus years tells me that behavior is multidetermined.

The authors tout the following joint statement on the impact of entertainment violence on children endorsed by several national health organizations: "The conclusion of the public health community, based on over 30 years of research, is that viewing entertainment violence can lead to increases in aggressive attitudes, values, and behavior, particularly in children." The statement was signed by several organizations, including the American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the American Academy of Pediatrics. Still, the joint statement also seems misleading to me.

My understanding of the 30 years of research on violence in the media is that although such violence has been shown to increase aggression, it does not necessarily cause an increase in violence. Aggression is a very broad term. At its lowest level, it can include alertness, initiative, curiosity, motivation, attentiveness, and exploratory behavior.

At the next level, aggression can encompass self-assertion, for example, the attempt to establish, maintain, and expand one’s boundaries and integrity while not intruding into the territory of others. Following self-assertion, there is dominance or the capacity to exert an influence on the behavior of other people or groups in an intended direction (also known as power), with the foundation of dominance being grounded in coercion, for example, the expectation of great rewards or punishments for certain kinds of behavior.

Authority, which is a form of dominance, is legitimized by legal, professional, or social mores and might be legitimate (authority conferred by virtue of law or formal designation), charismatic (authority bestowed by virtue of having "winning ways" with people, or traditional (authority granted out of respect for longevity).

Although hostility is a form of aggression, it includes behavior or attitudes intended to hurt or destroy an object or the self. Moreover, violence is a subcategory of hostility that occurs when there is the use of force to injure physically. Lastly, hatred is a form of aggression when the injury or destruction of an object, self, or situation is the end rather than a means to an end.

Former U.S. Surgeon General David Satcher’s seminal report on youth violence concludes that the average effect sizes of exposure to media violence on various measures of aggression range from small (r = 0.15) to quite large (r = 0.64). The evidence that exposure to media violence is a risk factor for violent behavior is more limited, with small average effect sizes of r = 0.06 in cross-sectional surveys, r = 0.13 in experimental studies, and r = 0.00-0.22 in longitudinal studies. Taken together, findings to date suggest that media violence has a relatively small impact on violence. The effect on aggression is stronger, ranging from small to moderate.

Finally, the Pediatrics article does not take into account the protective factors that prevent violence in the media from taking hold of young minds. I wrote about these protective factors in a Clinical Psychiatry News commentary published in May 2013.

In that piece, I cited the seven field principles that prevent risk factors:

• Rebuilding the village/constructing social fabric (known as building collective efficacy) – a good example of this is the creation of block clubs in which everyone on the block looks after one another and everyone’s children.

• Providing access to modern and ancient technology – both biotechnical and psychosocial.

• Improving bonding, attachment, and connectedness between people; resiliency research shows that if a young person has a good relationship with a caring adult who has the youth’s best interest at heart, that relationship is protective of the youth’s successful outcome.

• Providing an opportunity to improve self-esteem – a sense of power, a sense of models, a sense of uniqueness, and a sense of connectedness.

• Increasing opportunities to learn social and emotional skills of target recipients; a good example of this is anger management skills (technically known as affect regulation).

• Reestablishing the adult protective shield and monitoring risky behaviors by adults, thereby providing a sense of safety; a good example are the security procedures at the entrance to Chicago public schools.

• Minimizing the effects of trauma by cultivating learned helpfulness out of learned helplessness (aka, mastery), thus generating hope.

In summary, the authors are to be commended for documenting the increase in gun violence in the movies. However, to leap to unfounded conclusions that this has resulted in an increase in violence is an error.

Dr. Bell is professor of psychiatry and public health at the University of Illinois at Chicago. He also serves as a staff psychiatrist in the psychosis program in the department of psychiatry at the university, staff psychiatrist at St. Bernard’s Hospital, and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

When I read scientific publications on the impact of violence in the media, I am always ambivalent and skeptical. In my gut, intuitively, I believe that violence in the media must have an effect on youth. Yet, my understanding of research in this area tells me that the effect is not as significant as my intuition would have me believe.

In a recent study, Brad J. Bushman, Ph.D., of Ohio State University, Columbus, and his colleagues found that violence in films has more than doubled since 1950 (Pediatrics 2013 Nov. 11 [doi:10.1542/peds.2013-1600]). The researchers go on to suggest that the presence of guns in those films might increase the aggressive behavior of young people.

"In the wake of recent shooting sprees, legislators and the lay public are discussing possible ways to reduce youth violence," Dr. Bushman and his colleagues wrote. "What is conspicuously absent from these discussions, however, is the fact that just seeing a weapon can increase aggression, an effect dubbed the ‘weapons effect.’ "

I do not doubt the authors’ findings; for example, over the past 20 years the presence of guns in films has indeed increased dramatically. However, I think their conclusion that violent media can have harmful effects on children and youth through an increased weapons effect are misleading. Furthermore, their conclusions strike me as one-dimensional. My experience as a psychiatrist over the last 40-plus years tells me that behavior is multidetermined.

The authors tout the following joint statement on the impact of entertainment violence on children endorsed by several national health organizations: "The conclusion of the public health community, based on over 30 years of research, is that viewing entertainment violence can lead to increases in aggressive attitudes, values, and behavior, particularly in children." The statement was signed by several organizations, including the American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the American Academy of Pediatrics. Still, the joint statement also seems misleading to me.

My understanding of the 30 years of research on violence in the media is that although such violence has been shown to increase aggression, it does not necessarily cause an increase in violence. Aggression is a very broad term. At its lowest level, it can include alertness, initiative, curiosity, motivation, attentiveness, and exploratory behavior.

At the next level, aggression can encompass self-assertion, for example, the attempt to establish, maintain, and expand one’s boundaries and integrity while not intruding into the territory of others. Following self-assertion, there is dominance or the capacity to exert an influence on the behavior of other people or groups in an intended direction (also known as power), with the foundation of dominance being grounded in coercion, for example, the expectation of great rewards or punishments for certain kinds of behavior.

Authority, which is a form of dominance, is legitimized by legal, professional, or social mores and might be legitimate (authority conferred by virtue of law or formal designation), charismatic (authority bestowed by virtue of having "winning ways" with people, or traditional (authority granted out of respect for longevity).

Although hostility is a form of aggression, it includes behavior or attitudes intended to hurt or destroy an object or the self. Moreover, violence is a subcategory of hostility that occurs when there is the use of force to injure physically. Lastly, hatred is a form of aggression when the injury or destruction of an object, self, or situation is the end rather than a means to an end.

Former U.S. Surgeon General David Satcher’s seminal report on youth violence concludes that the average effect sizes of exposure to media violence on various measures of aggression range from small (r = 0.15) to quite large (r = 0.64). The evidence that exposure to media violence is a risk factor for violent behavior is more limited, with small average effect sizes of r = 0.06 in cross-sectional surveys, r = 0.13 in experimental studies, and r = 0.00-0.22 in longitudinal studies. Taken together, findings to date suggest that media violence has a relatively small impact on violence. The effect on aggression is stronger, ranging from small to moderate.

Finally, the Pediatrics article does not take into account the protective factors that prevent violence in the media from taking hold of young minds. I wrote about these protective factors in a Clinical Psychiatry News commentary published in May 2013.

In that piece, I cited the seven field principles that prevent risk factors:

• Rebuilding the village/constructing social fabric (known as building collective efficacy) – a good example of this is the creation of block clubs in which everyone on the block looks after one another and everyone’s children.

• Providing access to modern and ancient technology – both biotechnical and psychosocial.

• Improving bonding, attachment, and connectedness between people; resiliency research shows that if a young person has a good relationship with a caring adult who has the youth’s best interest at heart, that relationship is protective of the youth’s successful outcome.

• Providing an opportunity to improve self-esteem – a sense of power, a sense of models, a sense of uniqueness, and a sense of connectedness.

• Increasing opportunities to learn social and emotional skills of target recipients; a good example of this is anger management skills (technically known as affect regulation).

• Reestablishing the adult protective shield and monitoring risky behaviors by adults, thereby providing a sense of safety; a good example are the security procedures at the entrance to Chicago public schools.

• Minimizing the effects of trauma by cultivating learned helpfulness out of learned helplessness (aka, mastery), thus generating hope.

In summary, the authors are to be commended for documenting the increase in gun violence in the movies. However, to leap to unfounded conclusions that this has resulted in an increase in violence is an error.

Dr. Bell is professor of psychiatry and public health at the University of Illinois at Chicago. He also serves as a staff psychiatrist in the psychosis program in the department of psychiatry at the university, staff psychiatrist at St. Bernard’s Hospital, and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

When I read scientific publications on the impact of violence in the media, I am always ambivalent and skeptical. In my gut, intuitively, I believe that violence in the media must have an effect on youth. Yet, my understanding of research in this area tells me that the effect is not as significant as my intuition would have me believe.

In a recent study, Brad J. Bushman, Ph.D., of Ohio State University, Columbus, and his colleagues found that violence in films has more than doubled since 1950 (Pediatrics 2013 Nov. 11 [doi:10.1542/peds.2013-1600]). The researchers go on to suggest that the presence of guns in those films might increase the aggressive behavior of young people.

"In the wake of recent shooting sprees, legislators and the lay public are discussing possible ways to reduce youth violence," Dr. Bushman and his colleagues wrote. "What is conspicuously absent from these discussions, however, is the fact that just seeing a weapon can increase aggression, an effect dubbed the ‘weapons effect.’ "

I do not doubt the authors’ findings; for example, over the past 20 years the presence of guns in films has indeed increased dramatically. However, I think their conclusion that violent media can have harmful effects on children and youth through an increased weapons effect are misleading. Furthermore, their conclusions strike me as one-dimensional. My experience as a psychiatrist over the last 40-plus years tells me that behavior is multidetermined.

The authors tout the following joint statement on the impact of entertainment violence on children endorsed by several national health organizations: "The conclusion of the public health community, based on over 30 years of research, is that viewing entertainment violence can lead to increases in aggressive attitudes, values, and behavior, particularly in children." The statement was signed by several organizations, including the American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the American Academy of Pediatrics. Still, the joint statement also seems misleading to me.

My understanding of the 30 years of research on violence in the media is that although such violence has been shown to increase aggression, it does not necessarily cause an increase in violence. Aggression is a very broad term. At its lowest level, it can include alertness, initiative, curiosity, motivation, attentiveness, and exploratory behavior.

At the next level, aggression can encompass self-assertion, for example, the attempt to establish, maintain, and expand one’s boundaries and integrity while not intruding into the territory of others. Following self-assertion, there is dominance or the capacity to exert an influence on the behavior of other people or groups in an intended direction (also known as power), with the foundation of dominance being grounded in coercion, for example, the expectation of great rewards or punishments for certain kinds of behavior.

Authority, which is a form of dominance, is legitimized by legal, professional, or social mores and might be legitimate (authority conferred by virtue of law or formal designation), charismatic (authority bestowed by virtue of having "winning ways" with people, or traditional (authority granted out of respect for longevity).

Although hostility is a form of aggression, it includes behavior or attitudes intended to hurt or destroy an object or the self. Moreover, violence is a subcategory of hostility that occurs when there is the use of force to injure physically. Lastly, hatred is a form of aggression when the injury or destruction of an object, self, or situation is the end rather than a means to an end.

Former U.S. Surgeon General David Satcher’s seminal report on youth violence concludes that the average effect sizes of exposure to media violence on various measures of aggression range from small (r = 0.15) to quite large (r = 0.64). The evidence that exposure to media violence is a risk factor for violent behavior is more limited, with small average effect sizes of r = 0.06 in cross-sectional surveys, r = 0.13 in experimental studies, and r = 0.00-0.22 in longitudinal studies. Taken together, findings to date suggest that media violence has a relatively small impact on violence. The effect on aggression is stronger, ranging from small to moderate.

Finally, the Pediatrics article does not take into account the protective factors that prevent violence in the media from taking hold of young minds. I wrote about these protective factors in a Clinical Psychiatry News commentary published in May 2013.

In that piece, I cited the seven field principles that prevent risk factors:

• Rebuilding the village/constructing social fabric (known as building collective efficacy) – a good example of this is the creation of block clubs in which everyone on the block looks after one another and everyone’s children.

• Providing access to modern and ancient technology – both biotechnical and psychosocial.

• Improving bonding, attachment, and connectedness between people; resiliency research shows that if a young person has a good relationship with a caring adult who has the youth’s best interest at heart, that relationship is protective of the youth’s successful outcome.

• Providing an opportunity to improve self-esteem – a sense of power, a sense of models, a sense of uniqueness, and a sense of connectedness.

• Increasing opportunities to learn social and emotional skills of target recipients; a good example of this is anger management skills (technically known as affect regulation).

• Reestablishing the adult protective shield and monitoring risky behaviors by adults, thereby providing a sense of safety; a good example are the security procedures at the entrance to Chicago public schools.

• Minimizing the effects of trauma by cultivating learned helpfulness out of learned helplessness (aka, mastery), thus generating hope.

In summary, the authors are to be commended for documenting the increase in gun violence in the movies. However, to leap to unfounded conclusions that this has resulted in an increase in violence is an error.

Dr. Bell is professor of psychiatry and public health at the University of Illinois at Chicago. He also serves as a staff psychiatrist in the psychosis program in the department of psychiatry at the university, staff psychiatrist at St. Bernard’s Hospital, and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

As a public health psychiatrist, I have been interested in trauma, such as that stemming from gun-related homicides and other forms of violence, for more than 30 years. I’ve also published extensively on these public health challenges.

A recent report prepared by the National Science Foundation makes important distinctions between the different types of violence that are helpful as we try to understand these issues.

According to the report, rampage shootings in schools typically occur in "stable, close knit, low crime, and very rural towns." In these incidents, the shooter is usually a white adolescent male who does not have a history of medical treatment for mental disorders. These adolescents engage in antisocial behavior "to replace a damaged identity with a new and more satisfying one: the notorious, dangerous, hypermasculine antihero."

In contrast, urban shootings tend to take place in "densely populated areas with high crime levels and low social crime levels. Young people involved in these crimes "absorb a ‘code of the streets,’ which requires individuals to project ... a tough, violence-prone image in order to ward off threats they encounter in ordinary interaction."

Both categories of gun violence result in trauma, which frankly and sadly, makes our work as psychiatrists daunting.

When I hear about gun-related violence, regardless of the category, my first thought is this: We have a body of evidence that can be used to stop it. How? Let’s take a look at strategies that have worked in the past.

A little more than 100 years ago, Chicago experienced an influx of European immigrants as the city rebuilt from the Great Fire of 1871. Parents were working overtime to scrape out a living, and children had to work to contribute to the family’s livelihood. Jane Addams, the great social activist, described the children as "ill fed, ill housed, ill clothed, illiterate, and wholly untrained and unfit for any occupation." Families were disrupted by poverty and unfamiliar community circumstances. Sound familiar?

From 1875 to 1920, these conditions caused European immigrants' domestic violence in Chicago to be extraordinarily high; juvenile delinquency and violence were rampant. Fortunately, Jane Addams and her colleagues founded Hull House as a social settlement house "to aid in the solution of the social and industrial problems which are engendered by the modern conditions of life in a great city." This group of industrious women also developed the first Juvenile Court and the Institute for Juvenile Research (birthplace of child psychiatry) to strengthen families and to understand the causes of delinquency. Their methods, supported by the science of the day, proved successful for families disrupted by poverty and for disconnected communities.

A hundred years later, from 1992 to 1999, prevention researchers did research in 12 Chicago public schools. The research resulted in the Aban Aya Youth Project, a research project on violence, drug use, and early sexual debut prevention developed specifically for African American youth. In 2007, an independent team of national researchers examined 53 universal school-based programs that prevent violent and aggressive behavior, and affirmed Aban Aya as one of seven programs that had greatest design suitability and good execution. Based on the Aban Aya outcomes, seven "field principles" were created that government and community partners could use to reduce the likelihood that risk factors such as poverty and neighborhood disruption would automatically lead to violence and other negative behaviors in youth.

In short, these principles cultivate protective factors that prevent risk factors from leading to negative youth behaviors. The seven field principles are as follows:

• Rebuilding the village/constructing social fabric (known as building collective efficacy) – a good example of this is the creation of block clubs in which everyone on the block looks after one another and everyone’s children.

• Providing access to modern and ancient technology – both biotechnical and psychosocial.

• Improving bonding, attachment, and connectedness between people – resiliency research illustrates the reality that if youth have a good relationship with a caring adult who has the youth’s best interests at heart, it is protective of the youth’s successful outcome.

• Providing an opportunity to improve self-esteem – a sense of power, a sense of models, a sense of uniqueness, and a sense of connectedness.

• Increasing opportunities to learn social and emotional skills of target recipients – a good example of this is anger management skills (technically known as affect regulation.

• Reestablishing the adult protective shield and monitoring of risky behaviors by adults that can also be thought of as providing a sense of safety – a good example of these are the security procedures at the entrance of Chicago Public Schools.

• Minimizing the effects of trauma by cultivating learned helpfulness out of learned helplessness (a.k.a., mastery), thus generating hope.

The beauty of the principles is that many different activities can accomplish the outcomes the principles strive to achieve. For example, organizing a community soccer program can establish relationships among neighbors so they can all raise one another’s children; Little League baseball can teach youth social and emotional skills as they learn to play baseball with respect and emotional regulation; math clubs can provide a source for self-esteem; and religious activities or a church-sponsored garden can change the helplessness of hunger into the helpfulness of growing your own food.

The principles are focused enough to be "directionally correct," but flexible enough to accommodate differing neighborhoods, cultures, and resources within a community. These are strength-based approaches that not only reduce violence but also reduce risky sexual behaviors, the likelihood of drug use, decrease teen pregnancy, encourage successful school performance.

Although the science was less precise, if you examine what Jane Addams and her colleagues did to reduce violence and delinquency a hundred years ago and examine what we were able to do using the seven field principles developed from solid research methodology in the Chicago Public Schools, it becomes clear that the principles are the same. By using these principles and actualizing them, we were able to reduce violence in Chicago Public Schools by about 50% and decrease child abuse in Illinois. These strategies are tried and true – they worked before, and they can work again.

Where is Jane Addams when we need her?

Dr. Bell is professor of public health and director of the Institute for Juvenile Research in the department of psychiatry at the University of Illinois at Chicago.

As a public health psychiatrist, I have been interested in trauma, such as that stemming from gun-related homicides and other forms of violence, for more than 30 years. I’ve also published extensively on these public health challenges.

A recent report prepared by the National Science Foundation makes important distinctions between the different types of violence that are helpful as we try to understand these issues.

According to the report, rampage shootings in schools typically occur in "stable, close knit, low crime, and very rural towns." In these incidents, the shooter is usually a white adolescent male who does not have a history of medical treatment for mental disorders. These adolescents engage in antisocial behavior "to replace a damaged identity with a new and more satisfying one: the notorious, dangerous, hypermasculine antihero."

In contrast, urban shootings tend to take place in "densely populated areas with high crime levels and low social crime levels. Young people involved in these crimes "absorb a ‘code of the streets,’ which requires individuals to project ... a tough, violence-prone image in order to ward off threats they encounter in ordinary interaction."

Both categories of gun violence result in trauma, which frankly and sadly, makes our work as psychiatrists daunting.

When I hear about gun-related violence, regardless of the category, my first thought is this: We have a body of evidence that can be used to stop it. How? Let’s take a look at strategies that have worked in the past.

A little more than 100 years ago, Chicago experienced an influx of European immigrants as the city rebuilt from the Great Fire of 1871. Parents were working overtime to scrape out a living, and children had to work to contribute to the family’s livelihood. Jane Addams, the great social activist, described the children as "ill fed, ill housed, ill clothed, illiterate, and wholly untrained and unfit for any occupation." Families were disrupted by poverty and unfamiliar community circumstances. Sound familiar?

From 1875 to 1920, these conditions caused European immigrants' domestic violence in Chicago to be extraordinarily high; juvenile delinquency and violence were rampant. Fortunately, Jane Addams and her colleagues founded Hull House as a social settlement house "to aid in the solution of the social and industrial problems which are engendered by the modern conditions of life in a great city." This group of industrious women also developed the first Juvenile Court and the Institute for Juvenile Research (birthplace of child psychiatry) to strengthen families and to understand the causes of delinquency. Their methods, supported by the science of the day, proved successful for families disrupted by poverty and for disconnected communities.

A hundred years later, from 1992 to 1999, prevention researchers did research in 12 Chicago public schools. The research resulted in the Aban Aya Youth Project, a research project on violence, drug use, and early sexual debut prevention developed specifically for African American youth. In 2007, an independent team of national researchers examined 53 universal school-based programs that prevent violent and aggressive behavior, and affirmed Aban Aya as one of seven programs that had greatest design suitability and good execution. Based on the Aban Aya outcomes, seven "field principles" were created that government and community partners could use to reduce the likelihood that risk factors such as poverty and neighborhood disruption would automatically lead to violence and other negative behaviors in youth.

In short, these principles cultivate protective factors that prevent risk factors from leading to negative youth behaviors. The seven field principles are as follows:

• Rebuilding the village/constructing social fabric (known as building collective efficacy) – a good example of this is the creation of block clubs in which everyone on the block looks after one another and everyone’s children.

• Providing access to modern and ancient technology – both biotechnical and psychosocial.

• Improving bonding, attachment, and connectedness between people – resiliency research illustrates the reality that if youth have a good relationship with a caring adult who has the youth’s best interests at heart, it is protective of the youth’s successful outcome.

• Providing an opportunity to improve self-esteem – a sense of power, a sense of models, a sense of uniqueness, and a sense of connectedness.

• Increasing opportunities to learn social and emotional skills of target recipients – a good example of this is anger management skills (technically known as affect regulation.

• Reestablishing the adult protective shield and monitoring of risky behaviors by adults that can also be thought of as providing a sense of safety – a good example of these are the security procedures at the entrance of Chicago Public Schools.

• Minimizing the effects of trauma by cultivating learned helpfulness out of learned helplessness (a.k.a., mastery), thus generating hope.

The beauty of the principles is that many different activities can accomplish the outcomes the principles strive to achieve. For example, organizing a community soccer program can establish relationships among neighbors so they can all raise one another’s children; Little League baseball can teach youth social and emotional skills as they learn to play baseball with respect and emotional regulation; math clubs can provide a source for self-esteem; and religious activities or a church-sponsored garden can change the helplessness of hunger into the helpfulness of growing your own food.

The principles are focused enough to be "directionally correct," but flexible enough to accommodate differing neighborhoods, cultures, and resources within a community. These are strength-based approaches that not only reduce violence but also reduce risky sexual behaviors, the likelihood of drug use, decrease teen pregnancy, encourage successful school performance.

Although the science was less precise, if you examine what Jane Addams and her colleagues did to reduce violence and delinquency a hundred years ago and examine what we were able to do using the seven field principles developed from solid research methodology in the Chicago Public Schools, it becomes clear that the principles are the same. By using these principles and actualizing them, we were able to reduce violence in Chicago Public Schools by about 50% and decrease child abuse in Illinois. These strategies are tried and true – they worked before, and they can work again.

Where is Jane Addams when we need her?

Dr. Bell is professor of public health and director of the Institute for Juvenile Research in the department of psychiatry at the University of Illinois at Chicago.

As a public health psychiatrist, I have been interested in trauma, such as that stemming from gun-related homicides and other forms of violence, for more than 30 years. I’ve also published extensively on these public health challenges.

A recent report prepared by the National Science Foundation makes important distinctions between the different types of violence that are helpful as we try to understand these issues.

According to the report, rampage shootings in schools typically occur in "stable, close knit, low crime, and very rural towns." In these incidents, the shooter is usually a white adolescent male who does not have a history of medical treatment for mental disorders. These adolescents engage in antisocial behavior "to replace a damaged identity with a new and more satisfying one: the notorious, dangerous, hypermasculine antihero."

In contrast, urban shootings tend to take place in "densely populated areas with high crime levels and low social crime levels. Young people involved in these crimes "absorb a ‘code of the streets,’ which requires individuals to project ... a tough, violence-prone image in order to ward off threats they encounter in ordinary interaction."

Both categories of gun violence result in trauma, which frankly and sadly, makes our work as psychiatrists daunting.

When I hear about gun-related violence, regardless of the category, my first thought is this: We have a body of evidence that can be used to stop it. How? Let’s take a look at strategies that have worked in the past.

A little more than 100 years ago, Chicago experienced an influx of European immigrants as the city rebuilt from the Great Fire of 1871. Parents were working overtime to scrape out a living, and children had to work to contribute to the family’s livelihood. Jane Addams, the great social activist, described the children as "ill fed, ill housed, ill clothed, illiterate, and wholly untrained and unfit for any occupation." Families were disrupted by poverty and unfamiliar community circumstances. Sound familiar?

From 1875 to 1920, these conditions caused European immigrants' domestic violence in Chicago to be extraordinarily high; juvenile delinquency and violence were rampant. Fortunately, Jane Addams and her colleagues founded Hull House as a social settlement house "to aid in the solution of the social and industrial problems which are engendered by the modern conditions of life in a great city." This group of industrious women also developed the first Juvenile Court and the Institute for Juvenile Research (birthplace of child psychiatry) to strengthen families and to understand the causes of delinquency. Their methods, supported by the science of the day, proved successful for families disrupted by poverty and for disconnected communities.

A hundred years later, from 1992 to 1999, prevention researchers did research in 12 Chicago public schools. The research resulted in the Aban Aya Youth Project, a research project on violence, drug use, and early sexual debut prevention developed specifically for African American youth. In 2007, an independent team of national researchers examined 53 universal school-based programs that prevent violent and aggressive behavior, and affirmed Aban Aya as one of seven programs that had greatest design suitability and good execution. Based on the Aban Aya outcomes, seven "field principles" were created that government and community partners could use to reduce the likelihood that risk factors such as poverty and neighborhood disruption would automatically lead to violence and other negative behaviors in youth.

In short, these principles cultivate protective factors that prevent risk factors from leading to negative youth behaviors. The seven field principles are as follows:

• Rebuilding the village/constructing social fabric (known as building collective efficacy) – a good example of this is the creation of block clubs in which everyone on the block looks after one another and everyone’s children.

• Providing access to modern and ancient technology – both biotechnical and psychosocial.

• Improving bonding, attachment, and connectedness between people – resiliency research illustrates the reality that if youth have a good relationship with a caring adult who has the youth’s best interests at heart, it is protective of the youth’s successful outcome.

• Providing an opportunity to improve self-esteem – a sense of power, a sense of models, a sense of uniqueness, and a sense of connectedness.

• Increasing opportunities to learn social and emotional skills of target recipients – a good example of this is anger management skills (technically known as affect regulation.

• Reestablishing the adult protective shield and monitoring of risky behaviors by adults that can also be thought of as providing a sense of safety – a good example of these are the security procedures at the entrance of Chicago Public Schools.

• Minimizing the effects of trauma by cultivating learned helpfulness out of learned helplessness (a.k.a., mastery), thus generating hope.

The beauty of the principles is that many different activities can accomplish the outcomes the principles strive to achieve. For example, organizing a community soccer program can establish relationships among neighbors so they can all raise one another’s children; Little League baseball can teach youth social and emotional skills as they learn to play baseball with respect and emotional regulation; math clubs can provide a source for self-esteem; and religious activities or a church-sponsored garden can change the helplessness of hunger into the helpfulness of growing your own food.

The principles are focused enough to be "directionally correct," but flexible enough to accommodate differing neighborhoods, cultures, and resources within a community. These are strength-based approaches that not only reduce violence but also reduce risky sexual behaviors, the likelihood of drug use, decrease teen pregnancy, encourage successful school performance.

Although the science was less precise, if you examine what Jane Addams and her colleagues did to reduce violence and delinquency a hundred years ago and examine what we were able to do using the seven field principles developed from solid research methodology in the Chicago Public Schools, it becomes clear that the principles are the same. By using these principles and actualizing them, we were able to reduce violence in Chicago Public Schools by about 50% and decrease child abuse in Illinois. These strategies are tried and true – they worked before, and they can work again.

Where is Jane Addams when we need her?

Dr. Bell is professor of public health and director of the Institute for Juvenile Research in the department of psychiatry at the University of Illinois at Chicago.

As the country struggles to process the horrific massacre in Newtown, Conn., those of us who treat patients with mental illness must keep several facts in mind.

We know that 20,000 out of 100,000 people in the United States have a mental illness and that much of this is depression. In addition, an estimated 1 million adults in the United States reported making a suicide attempt in the past year.

Finally, it turns out that overall, for the last 30 years, the suicide rates run around 11/100,000 people across all age ranges and 20/100,000 for young adults. This makes suicide the third-leading cause of death among young people. Yet, suicide is actually a rare event. Furthermore, the likelihood of a person committing a single homicide before committing suicide is even rarer.

As an expert in violence prevention who has been investigating these phenomena for 45 years, I view such incidents as "suicides preceded by mass murder" (mass murder defined as three or more people being killed). The problem is there is no solid evidence for this theory. Also, these kinds of suicides are even rarer and even more difficult to study with the goal of preventing these tragedies.

Of course, if people get their understanding about public health and the frequency of certain events from the media, they believe such events are not rare, but rather are quite common. These difficulties make it tricky for public psychiatrists to inform public policy and public opinion to do things that prevent these horrible events from occurring and repeating.

When an individual commits suicide and the media give that suicide a great deal of coverage, shortly afterward, there are what are called "copycat" or "contagion" suicides – this was David Phillips’s seminal work back in the 1970s. The proof is so strong that the American Foundation for Suicide Prevention, the American Association of Suicidology, and the Annenberg Public Policy Center have provided "Reporting on Suicide: Recommendations for the Media." These guidelines suggest that the media not give a great deal of attention to the phenomenon of suicide, and it begins with the assertion that "Suicide contagion is real."

Those of us who work with these patients know that when the media provide details about these suicides, they provide depressed, hurt individuals who express their pain through anger and violence with a blueprint for what to do with their suicidal ideation. We know that a huge dynamic in the thinking of suicidal people is often: "I’ll fix you; I’ll kill myself." Unfortunately, some people take this a step further and think: "I’ll show you; not only will I kill myself, but I will kill a bunch of other people first." Fortunately, as I said earlier, this is an extremely rare event – despite the perception perpetuated by the mainstream media that this is common.

In light of these facts, I have several recommendations:

• First, I realize that the media cannot ignore these horrific events, but it could report on them differently to minimize what I suspect is contagion.

• Second, we can increase the protective factors that generally prevent more suicides from occurring.

Here are four steps we can take to stop these events:

1. We can increase the social fabric surrounding mentally ill people, which entails not being afraid of them and not stigmatizing them.

2. We can ensure that all youth are strongly connected to people so they will be able to feel good about their relationships and about themselves. Such support systems help ease some of the pain caused by depression.

3. We can teach all of our children social and emotional skills such as "affect regulation" so that "hurt people will not hurt people."

4. We can monitor our young adults (that is, anyone under 26), because research shows that brain development is a gradual process. The limbic system (the flight, fight, or freeze system of the brain) is the first to develop. The frontal lobes, where thinking, judgment, and wisdom occur, are not fully developed until age 26 – in other words, young adults tend to be all gasoline and no brakes or steering wheel. Thus, it is up to families, schools, friends, and neighbors to supply the brakes and steering wheels for young adults in a loving manner – not a punitive one – so they are influenced by formal and informal social controls that prevent risky behaviors.

• Lastly, the 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action, if followed, could prevent "suicides preceded by mass murder."

Dr. Bell is professor of public health and director of the Institute for Juvenile Research in the department of psychiatry at the University of Illinois at Chicago. He has written extensively on the issue of suicide and homicide, and was appointed to serve on the Institute of Medicine’s Board of Neuroscience and Behavioral Health study on pathophysiology and prevention of adolescent and adult suicide in 2000 that produced the seminal IOM report "Reducing Suicide" in 2002. Dr. Bell also worked with former U.S. Surgeon General David Satcher on "Youth Violence: A Report of the Surgeon General" in 2001.

As the country struggles to process the horrific massacre in Newtown, Conn., those of us who treat patients with mental illness must keep several facts in mind.

We know that 20,000 out of 100,000 people in the United States have a mental illness and that much of this is depression. In addition, an estimated 1 million adults in the United States reported making a suicide attempt in the past year.

Finally, it turns out that overall, for the last 30 years, the suicide rates run around 11/100,000 people across all age ranges and 20/100,000 for young adults. This makes suicide the third-leading cause of death among young people. Yet, suicide is actually a rare event. Furthermore, the likelihood of a person committing a single homicide before committing suicide is even rarer.

As an expert in violence prevention who has been investigating these phenomena for 45 years, I view such incidents as "suicides preceded by mass murder" (mass murder defined as three or more people being killed). The problem is there is no solid evidence for this theory. Also, these kinds of suicides are even rarer and even more difficult to study with the goal of preventing these tragedies.

Of course, if people get their understanding about public health and the frequency of certain events from the media, they believe such events are not rare, but rather are quite common. These difficulties make it tricky for public psychiatrists to inform public policy and public opinion to do things that prevent these horrible events from occurring and repeating.

When an individual commits suicide and the media give that suicide a great deal of coverage, shortly afterward, there are what are called "copycat" or "contagion" suicides – this was David Phillips’s seminal work back in the 1970s. The proof is so strong that the American Foundation for Suicide Prevention, the American Association of Suicidology, and the Annenberg Public Policy Center have provided "Reporting on Suicide: Recommendations for the Media." These guidelines suggest that the media not give a great deal of attention to the phenomenon of suicide, and it begins with the assertion that "Suicide contagion is real."

Those of us who work with these patients know that when the media provide details about these suicides, they provide depressed, hurt individuals who express their pain through anger and violence with a blueprint for what to do with their suicidal ideation. We know that a huge dynamic in the thinking of suicidal people is often: "I’ll fix you; I’ll kill myself." Unfortunately, some people take this a step further and think: "I’ll show you; not only will I kill myself, but I will kill a bunch of other people first." Fortunately, as I said earlier, this is an extremely rare event – despite the perception perpetuated by the mainstream media that this is common.

In light of these facts, I have several recommendations:

• First, I realize that the media cannot ignore these horrific events, but it could report on them differently to minimize what I suspect is contagion.

• Second, we can increase the protective factors that generally prevent more suicides from occurring.

Here are four steps we can take to stop these events:

1. We can increase the social fabric surrounding mentally ill people, which entails not being afraid of them and not stigmatizing them.

2. We can ensure that all youth are strongly connected to people so they will be able to feel good about their relationships and about themselves. Such support systems help ease some of the pain caused by depression.

3. We can teach all of our children social and emotional skills such as "affect regulation" so that "hurt people will not hurt people."

4. We can monitor our young adults (that is, anyone under 26), because research shows that brain development is a gradual process. The limbic system (the flight, fight, or freeze system of the brain) is the first to develop. The frontal lobes, where thinking, judgment, and wisdom occur, are not fully developed until age 26 – in other words, young adults tend to be all gasoline and no brakes or steering wheel. Thus, it is up to families, schools, friends, and neighbors to supply the brakes and steering wheels for young adults in a loving manner – not a punitive one – so they are influenced by formal and informal social controls that prevent risky behaviors.

• Lastly, the 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action, if followed, could prevent "suicides preceded by mass murder."

Dr. Bell is professor of public health and director of the Institute for Juvenile Research in the department of psychiatry at the University of Illinois at Chicago. He has written extensively on the issue of suicide and homicide, and was appointed to serve on the Institute of Medicine’s Board of Neuroscience and Behavioral Health study on pathophysiology and prevention of adolescent and adult suicide in 2000 that produced the seminal IOM report "Reducing Suicide" in 2002. Dr. Bell also worked with former U.S. Surgeon General David Satcher on "Youth Violence: A Report of the Surgeon General" in 2001.

As the country struggles to process the horrific massacre in Newtown, Conn., those of us who treat patients with mental illness must keep several facts in mind.

We know that 20,000 out of 100,000 people in the United States have a mental illness and that much of this is depression. In addition, an estimated 1 million adults in the United States reported making a suicide attempt in the past year.

Finally, it turns out that overall, for the last 30 years, the suicide rates run around 11/100,000 people across all age ranges and 20/100,000 for young adults. This makes suicide the third-leading cause of death among young people. Yet, suicide is actually a rare event. Furthermore, the likelihood of a person committing a single homicide before committing suicide is even rarer.

As an expert in violence prevention who has been investigating these phenomena for 45 years, I view such incidents as "suicides preceded by mass murder" (mass murder defined as three or more people being killed). The problem is there is no solid evidence for this theory. Also, these kinds of suicides are even rarer and even more difficult to study with the goal of preventing these tragedies.

Of course, if people get their understanding about public health and the frequency of certain events from the media, they believe such events are not rare, but rather are quite common. These difficulties make it tricky for public psychiatrists to inform public policy and public opinion to do things that prevent these horrible events from occurring and repeating.

When an individual commits suicide and the media give that suicide a great deal of coverage, shortly afterward, there are what are called "copycat" or "contagion" suicides – this was David Phillips’s seminal work back in the 1970s. The proof is so strong that the American Foundation for Suicide Prevention, the American Association of Suicidology, and the Annenberg Public Policy Center have provided "Reporting on Suicide: Recommendations for the Media." These guidelines suggest that the media not give a great deal of attention to the phenomenon of suicide, and it begins with the assertion that "Suicide contagion is real."

Those of us who work with these patients know that when the media provide details about these suicides, they provide depressed, hurt individuals who express their pain through anger and violence with a blueprint for what to do with their suicidal ideation. We know that a huge dynamic in the thinking of suicidal people is often: "I’ll fix you; I’ll kill myself." Unfortunately, some people take this a step further and think: "I’ll show you; not only will I kill myself, but I will kill a bunch of other people first." Fortunately, as I said earlier, this is an extremely rare event – despite the perception perpetuated by the mainstream media that this is common.

In light of these facts, I have several recommendations:

• First, I realize that the media cannot ignore these horrific events, but it could report on them differently to minimize what I suspect is contagion.

• Second, we can increase the protective factors that generally prevent more suicides from occurring.

Here are four steps we can take to stop these events:

1. We can increase the social fabric surrounding mentally ill people, which entails not being afraid of them and not stigmatizing them.

2. We can ensure that all youth are strongly connected to people so they will be able to feel good about their relationships and about themselves. Such support systems help ease some of the pain caused by depression.

3. We can teach all of our children social and emotional skills such as "affect regulation" so that "hurt people will not hurt people."

4. We can monitor our young adults (that is, anyone under 26), because research shows that brain development is a gradual process. The limbic system (the flight, fight, or freeze system of the brain) is the first to develop. The frontal lobes, where thinking, judgment, and wisdom occur, are not fully developed until age 26 – in other words, young adults tend to be all gasoline and no brakes or steering wheel. Thus, it is up to families, schools, friends, and neighbors to supply the brakes and steering wheels for young adults in a loving manner – not a punitive one – so they are influenced by formal and informal social controls that prevent risky behaviors.

• Lastly, the 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action, if followed, could prevent "suicides preceded by mass murder."

Dr. Bell is professor of public health and director of the Institute for Juvenile Research in the department of psychiatry at the University of Illinois at Chicago. He has written extensively on the issue of suicide and homicide, and was appointed to serve on the Institute of Medicine’s Board of Neuroscience and Behavioral Health study on pathophysiology and prevention of adolescent and adult suicide in 2000 that produced the seminal IOM report "Reducing Suicide" in 2002. Dr. Bell also worked with former U.S. Surgeon General David Satcher on "Youth Violence: A Report of the Surgeon General" in 2001.