12Apr/19

On Suicide, Part Two

I’ve spent a lot of time over the last year reading books and articles on suicide. One book is Stay, which was written by Jennifer Hecht. She chronicles the history of suicide and the philosophical, religious, and civil arguments for and against it (post renaissance philosophers were the only ones that advocated for the right to kill oneself). I won’t rehash them here.

But I do want to summarize her two main arguments against suicide.

  1. “We owe it to society at large, and especially our personal communities, to stay alive.” (6)

The death of a friend or loved one causes great pain. There is the searing emotional agony, as well as growing recognition of permanent absence. Depending upon how present the departed was in another’s life, the more empty time is left. For many, it is a dreadful struggle back to a regular routine. That person’s pain and hardship is passed on to others, even those that didn’t know the deceased. The shockwaves ripple outward.

Ms. Hecht also wrote about the domino effect of suicides. “One of the best predictors of suicide is knowing a suicide.” (x) I would argue that there are proximity and mass domino effects as well: The closer that a completed suicide is to you, the more likely one is to attempt. And the more people you know that completed suicide, the more likely you are to attempt as well.

2. We owe it to our future selves.

Over a decade ago, I read Nick Hornby’s A Long Way Down. It is a novel about four people who meet at the top of a building in London on New Year’s Eve. They all planned to kill themselves, but didn’t because they were in the presence of others (suicide tends to be quite private). Mr. Hornby’s book (which has numerous comic moments) was well researched and took the subject very seriously. A key point was made, which is that most people that contemplate suicide move on if they survive the next 90 days. Many of us know cases where people considered suicide for years, even decades, but they tend to be outliers.

Since 2010, I have been telling friends with children that they should make deals with their kids. “I’ll buy this toy for you now, but you must promise to work five hours every Saturday in the garden at ages 14, 15, and 16” or some deal like that with their seven year old child (and get them to sign a paper and video record it). Kids have little to no sense of the time and long term consequences. Imagine how irritated your 14 year old would be when you produce the contract and the video.

“I can’t be held to what I wanted when I was 7!” they’d probably shout. The same probably goes for a deal made at 19 that is called in at 27, and so on and so on.

Back to suicide. I’ve worked with well over 100 people who were truly suicidal that did not kill themselves. Most of them are long past those thoughts and impulses, and have expressed gratitude that they did not go through with it. I have heard some version of the phrase, “I’m really glad that I didn’t kill myself. Things are so much better these days” then most will probably believe. But hopefully you will believe me.

____________

Ms. Hecht’s book concludes with this:

None of us can truly know what we mean to other people, and none of us can know what our future self will experience. History and philosophy ask us to remember these mysteries, to look around at friends, family, humanity, at the surprises that life brings — the endless possibilities that living offers — and to persevere. There is love and insight to live for, bright moments to cherish, and even the possibility of happiness, and the chance of helping someone else through his or her own troubles. Know that people, through history and today, understand how much courage it takes to stay. Bear witness to the night side of being human and the bravery it entails, and wait for the sun. If we meditate on the record of human wisdom we may find there reason enough to persist and find our way back to happiness. The first step is to consider the arguments and evidence and choose to stay. After that, anything may happen. First, choose to stay.

 

16Dec/18

On Suicide, Part One

I’m finally ready to start writing about suicide.

This year alone, I’ve read a number of books and hundreds of articles about it. My original plan was to write a single piece, but I found that I just have too much to say about that confounding and complex topic. Suicide. It evokes a range of powerful thoughts and emotions.

It is different than other deaths. Accidents, overdoses, and murders are also tragic and painful. In no way am I trying to diminish other ways of dying or rank them in some kind of ridiculous scale.

My mother lost three of the other four members of her nuclear family when I was 2 1/2 years old (she was not yet 40). Her sister, whom she shared a room with when they were growing up in Minneapolis, killed herself by drowning in the Mississippi river. I was immediately told what happened, despite my young age and the inability to really comprehend death at that stage of life. I think my parents did the right thing telling me. They explained that she was sick and took her own life and that my mother was very sad. Mom was a trooper though. She talked about it a lot (I was embarrassed as a child how often it came up in her conversations with others), but she was highly functional. I have no memories of her staying in bed, wailing away or silently brooding while looking out a window. I was a young adult before I really understood how much of an impact her sister’s suicide must have had on her. My mother’s process provided a model for the work I encourage others to do in the face of loss: talk about it, spend time with friends and family, and continue to move forward in life.

Earlier this year, my mom wrote about her sister for my first book. I was startled by something that I had never previously thought about: they shared a room growing up for over a decade (maybe two decades). That type of proximity over such a long period of time suggests a close relationship, or at the very least, a deep knowledge of one another. Late night conversations after the lights go out. Familiarity with early morning routines. Everyday exposure to what they are reading. Intimate understanding of facial expressions and physical gestures.

A couple kids in my high school committed suicide. I knew their names but I didn’t know them. It was a shock. I grew up in a time and place where nothing bad seemed to happen; put better, nothing bad happened to me. There were kids who had private hells that we didn’t know about. The morning in a high school after a suicide is an eerie place. The collective pep and bounce of teenagers has been drained. The day seems long and in slow motion. Laughing and planning feel guilty. The adults stumble with what to say.

There has been a lot of death in my life (that is eventually true for all humans, but usually weighted towards the end of our lives when we have more experience and wisdom to process it). My grandmother when I was 19. Fraser from an overdose when I was 26. Eric suddenly when I was 41. Dozens of students and clients. Soldiers and veterans that I have treated. I also work with the survivors. Hundreds of parents. A few young children of cops.

All of this is prelude to the only point I really want to make today, and one that I may have been able to get to in the third paragraph. I had a close friend complete suicide. I felt a deep sadness, confusion, and a bit of anger. That is almost the universal human response. There is something else though: a feeling of deficiency.

What is wrong with me and my relationship that someone I was so close with sought to kill himself?

It hangs on the edges of our brain and is rarely uttered. This was an invasive thought that popped into my head in the early weeks after my friend’s suicide. It must be far worse for a romantic partner or family member. I suspect that it is unfathomable and unbearable for a young son or daughter. “What is wrong with me?” Perpetually thought but almost never spoken.

It must be said out loud. It must be processed. Because I have an answer. There is nothing deficient about you. Suicide is terrible. Horrible. Do not make it about you, even if every waking instinct tells you to do so. It isn’t. This is why we must talk to other people about it.

27Nov/18

Do You Have To Be in Recovery to Help Someone with Addiction? (and other myths)

Do you have to be in recovery to help someone with a drug problem?

No.

That is the unequivocal answer, but I am happy to make my case with another 958 words. There are a few other foolish assertions that should be addressed as well. Over the years, I have heard the following statements out of numerous AA members, paraprofessionals, and licensed therapists:

  • Only you can decide if you are an alcoholic
  • No one shows up to an AA meeting by accident
  • Only an addict can help another addict
  • If you haven’t lived it, you don’t know it
  • People in recovery are better at working with substance abusers and others in recovery

Let’s address these one at a time.

  • Only you can decide if you are an alcoholic

This is a ridiculous assertion. We do not allow individuals to diagnose their own depression, anxiety, diabetes, cancer, HIV, or heart disease. One of the most common defense mechanisms that people with alcohol and/or other substance misuse disorders use is denial. A common form of denial is blaming others (I had a rough childhood, my girlfriend is mean, marijuana should be legalized, the cops were out to get me, school/work cause me a lot of stress). Another major form of denial is minimizing: they will say I’ve never been arrested. If they’ve been arrested, they’ll say I’ve never been to jail. And so on with prison. We can play this game with alcohol, then pills, then heroin, then needles and then sticking needles in the neck. Waiting for a person to admit they have a substance abuse problem is a poor plan, whether you are a family member, friend, member of AA, or professional counselor. Licensed medical professionals are trained in assessing and diagnosing. Some are clearly better at it than others, but they can do an excellent job at getting past denial.

  • No one shows up to an AA meeting by accident

I showed up to a Gambler’s Anonymous meeting by accident once. The GA members welcomed me, asked me 20 questions in the middle of the meeting and then eventually said, a bit disappointedly, “you don’t have a gambling problem.” Over the last 10 years, I have sent hundreds of nursing, pharmacy, communication, social work, and law students to open 12-step meetings to learn more about addiction, recovery and the power of communities. Courts have forced people to attend meetings who made a mistake or committed a crime, but don’t meet diagnostic criteria. There are dozens of young people I’ve met whose parents forced them to attend meetings because they caught their son or daughter smoking pot or were outraged that they came home drunk. People show up to meetings by accident, and they are sometimes sent to one when they don’t have a problem.

  • Only an addict can help another addict

I got clean and sober at 19 (I’m 40 now). When I went to treatment, every counselor and paraprofessional there was in recovery themselves. They talked about their own experiences a lot. Because of their openness, I felt both less alone and less like an outcast. I thought everyone that worked in the field should be in recovery. I had a psychologist who was not in recovery. He helped me with improving relations with family members, discuss college life, navigate job conflicts, point out my faults in romantic relationships and generally become a better version of myself (and better person). After graduating from Rutgers, I took a job in a long term treatment program. Every counselor and paraprofessional was in recovery. Many didn’t attend 12-step meetings outside of work, most had a lot of countertransference issues and there were several with real boundary problems. I remember thinking, “man…people in recovery really shouldn’t be in this field.” I left that job for an outpatient program where less than half of the clinicians were in recovery – I found there were some really good therapists in recovery, really good ones not in recovery, not so good ones in recovery, and not so good ones not in recovery. I am going to belabor my point. We don’t ask suicidal people (or formerly suicidal people) to work with those with current suicidal ideations. Most cardiologists are not in remission from heart disease.

  • If you haven’t lived it, you don’t know it

I figure I’ve used over 2,000 toilets around America and in 21 other countries on four different continents. I can’t fix toilets for @#$%. This is the kind of folk wisdom that you might hear in a 12-step meeting sometime, but I turn it on its head by claiming ignorance in the face of experience rather than expertise from experience. Experience with a problem can be helpful in dealing with an issue or treating someone else, but it isn’t a requirement. I have never had depression, been bullied because I was gay, gotten cancer, overdosed on opiates or lost a child, but I’ve helped people with those problems over the years. And I’ve been very effective at it. I find that people that claim an expertise because of their own recovery most likely don’t have other knowledge, education, training, or skills that they can utilize to help people.

  • People in recovery are better at working with substance abusers and others in recovery

I used to believe in this. Then I worked at that aforementioned program where everyone was in recovery and many of them were terrible at their job. If someone is in recovery, they might be able to use their personal narrative to connect with someone. But there are people who are not in recovery who have stories that can also connect with others and help get them to open up and consider making behavioral changes. I’ve known a number of great clinicians who are not in recovery, and the statement that people in recovery are better than them is not only offensive, it is false.

 

*I wrote this for Hazelden back in October of 2016. It was recently taken down from their website, so I have republished it here.

03Nov/18

A Veterans Day Story

My close friend and colleague Eric Arauz died in March. I wrote about him everyday for one month. Others followed suit. I took a bunch of the stories and made them into a book, which was published last month. Eric served in the Navy during Gulf War I, back in the 1990’s. He described himself as “a poor sailor but a great veteran.” He loved talking to other veterans and he was an excellent advocate for them, especially those with mental health and/or addiction issues.

Near the end of October, I traveled to the Psych Congress annual conference in Orlando. I was invited by the organizers to come down and talk about Eric. They honored him by naming the kickoff keynote after him and also creating an award in his name. Very cool. I read a few sections from the book. Before I closed with my chapter on Eric at Elizabeth High School, I mentioned how I really would have liked to tell him the story about an Army veteran that I met a week earlier in Philadelphia.

Independence Blue Cross of Pennsylvania put on an all day event about the Opioid Epidemic at the Kimmel Center in Philadelphia. There were four panel discussions and a keynote speaker. I was impressed with the event, and every panel had at least one truly impressive person. The keynote took place just after lunch. The speaker was retired U.S. Army Master Sergeant (MSG) Justin Minyard.

MSG Minyard is a big guy (over 6’5″). He wore a suit, no tie (I approved). His hair was short but he had grown a beard. MSG Minyard began his talk with an apology. “I had a traumatic brain injury,” he said, “and there are times that I can’t get my mouth to say what I am thinking. As frustrating it is for you to watch me pause and stumble, it is even more frustrating for me. Please bear with me.” It was a powerful introduction, and my heart went out to him. I think that most of the audience had a similar reaction.

MSG Minyard was stationed near Washington, DC in the late 90’s and early 00’s. He was on details for both President Clinton and President Bush II, and he also had the honorable task of guarding the Tomb of the Unknown Soldier. Within a couple of hours of the attack on the Pentagon on 9/11, MSG Minyard and his unit were at the site trying to rescue people trapped under the rubble. “I was trying to reach a woman who was trapped under three floors of debris and while trying to reach her a load bearing wall collapsed on me and I had spinal damage and had to have several discs removed.” He was 21 years old.

MSG Minyard was a good soldier but a terrible patient. He cut his physical therapy time by more than half and demanded to be returned to the field. He served multiple tours in Iraq and Afghanistan (at least five) and was injured on several occasions. He told a story about how he and a half dozen other special forces operatives were tasked with attacking a bunker in a city. The helicopter was 60 feet above the target. Just as MSG Minyard jumped out of the chopper and went to grab the rope to repel down, they took incoming fire and the helicopter swerved. MSG Minyard was not able to grab the rope and he fell the entire 60 feet. To compound matters, the soldiers that came after him (down the rope) landed on him, exacerbating his back injury.

To deal with the pain and trauma, he was prescribed Oxycodone and Valium. During his speech, MSG Minyard filled a glass with his daily drug cocktail. Then he filled up a glass vase with his monthly dosage. It was a powerful effect and the audience gasped. He lived this way for almost three years. It devastated his wife and his daughter.

“It got to the point that when my four year old daughter asked me to read her a bed time story, I would respond to her with the worst words possible at the highest volume, just inches from her face. Because if I read to her, that was 15 minutes that I could not spare because the CVS would close and I would not be able to get my medication and I’d go into a horrible withdrawal.”

Silence. And then, “I did that. I’m responsible for that. I can never undo what I put my ex-wife and daughter through.”

He talked to therapists and doctors. More than two and half years into his prescribed addiction, someone talked to him about alternative ways to deal with pain. “Why am I just hearing about this now?” he asked.

More silence. And then, “Think about this. I’m just a big dumb Army guy, but I did guard two Presidents and the Tomb of the Unknown Soldier. I was deployed multiple times and worked on highly important missions. I had access to care and support. If this can happen to me, it can happen to anyone around America.”

MSG Minyard was given spinal cord stimulation and got off his pills. The recovery process was difficult. He has been clean and sober for about eight years and now works for Boston Scientific (the company that developed the spinal cord stimulation technology). He said that he still has pain, but it is mostly manageable. He finished by talking about his 11 year old daughter and how she still wants to hang out with him (“at least for another year and a half”). He takes her to “an expensive park in Orlando” and they walk around all day and evening. The all day walking causes him pain, but he does it for his daughter.

He earned a standing ovation, even from me (I rarely do that). I left my seat and forced my way backstage, past staffers and security. MSG Minyard was drinking water and was guarded by two off-duty Philadelphia police officers. I went up to him and introduced myself. We shook hands. I told him what I do and I thanked him for his talk.

And then I asked him if he wore cufflinks. He said yes.

“Do you have a pair of Army cufflinks?” I asked him.

“No.”

I started to take mine off. He saw what I was doing and said, “Sir, I can’t possibly take those.”

“Sergeant, you’ve earned them. Wear them with gratitude and pride.”

One of the cops turned towards MSG Minyard and said, “You have to take them. He outranks you.” Then the cop turned to me and saluted.

With tears in our eyes, we all shook hands. I gave him my card and told him that I’d like to connect and possible bring him to Rutgers for a talk. As I started to walk away, my first thought was that Arauz would have loved that guy’s speech and my gesture. It was a resurrection story.

A Veterans Day story.

 

14Oct/18

On Death and Grieving

In early October, a very close friend reached out to me via text to tell me a friend of his had died that day. Just 39 years old, the man had succumbed to his substance misuse disorder after many years of complete sobriety. When my aforementioned friend lost someone very close to him in 2014, I sent an email out about what he (and others) might want to do in both the immediate and long-term aftermath. He asked me for that advice again. I sent him a longer version, which I’m posting here for the public (I’ve edited out the deceased name).

What you should do:

  • Write down everything you can about him/her. Things he said, things you did together, jokes played, things that pissed you off and little gestures. Your mind will be flooded with memories over the next two weeks, and then they will slowly fade. You will never remember him as well as you do right now. Write it down. Also…it will help you grieve. Do this every day, for 30 days, without fail.
  • Keep up your exercise routine. If you don’t exercise, you should start.
  • Consider seeing a therapist who specializes in grief and loss.

What you should avoid:

  • Avoid isolating after the first 24 hours. Humans (and animals) have a tendency to crawl into a hole when injured or sad and avoid contact. It is a terrible instinct for grieving. Having people around, even if you don’t discuss the death, is helpful. Maybe not 24/7, but certainly daily. I am incredibly grateful for my friends who realized that they should stop by for a meal or watch baseball or just hang around during my various periods of grieving.
  • Do not take in more caffeine or nicotine than usual.
  • Be aware of your eating. Some of you may have no appetite, while others will seek comfort in food. Both options have negative consequences. Try to keep up your regular diet.
  • If you are someone who uses eating, drinking, drugging, sex, gambling or shopping to feel good or self-treat, be very wary over the next three months. If you are in recovery from one or more of these issues, consider talking to friends who are also in recovery or upping your support group attendance.

What you should be aware of:

  • I was angry at Fraser for dying and then I would feel bad about being angry at my dead friend. It was confusing. It took me a while to reconcile all of those feelings.
  • You have the right to talk with who you want about this, and you can also tell people that you are sad and just need some space. I found that I talked about it a lot with a couple of close friends, shared about it at every meeting I went to and discussed it in therapy. But I didn’t have it in me to talk to everyone. Some people just pissed me off or didn’t “get it.”
  • Everyone grieves differently. Everyone. Don’t fight with those close to you because you don’t like the way they grieve.
  • Remember that his/her family’s pain is worse than yours. Writing a letter to them about how much he meant to you, as well as some funny/good stories will be valued more than you can possibly know.

I’ve written a lot about death and grieving over the last four+ years. I have provided some baseline advice in this article, but for more specific situations, you might want to check one or more of the pieces below.

In the spring of 2014, Rutgers published a story about my work and how I was inspired after the death of my childhood friend Fraser Curry. I wrote a follow-up piece about my reaction to his death and what people can do if they have a friend or family member with a drug problem: http://greenagel.com/what-to-do-when-your-friend-or-family-member-has-a-drug-problem/

When my friend Pat died, I wrote this in 2014: http://greenagel.com/our-friend-pat/

This is a (near) copy of a speech I gave at an Overdose Vigil to 350+ parents who lost a child to addiction: http://greenagel.com/to-the-parents-who-have-lost-a-child/

A long-time patient of mine died in December of 2016 and I wrote this for myself and other counseling professionals: http://greenagel.com/on-the-death-of-my-patient/

A cousin of mine lost a baby in 2017 and I wrote this: http://greenagel.com/to-the-parents-who-lost-a-young-child/

I lost one of my closest friends (and my closest co-worker) this past March. I followed almost all of the advice that I’ve laid out (I didn’t work out for three weeks and I over ate). My writing turned into a book and it was released on October 8th on Amazon. It is titled The Book of Eric and it provides an example of how to deal with loss and grief.

14Sep/18

A Soldier and a Wonderful Leader

 

 

 

 

Master Sergeant Greg Spadoni. Served in the United States Army for 35 years. Our time in the NJ Army National Guard lasted from 1996 to 2002. This is a brief tribute that will not nearly say enough about the man.

I met him in September of 1996 when I joined my NJ National Guard Unit, fresh out of Ft. Knox. He introduced himself as a friend of a family friend and told me to find him if I had any questions. “Or if anyone bothers you,” he said.

“Why would anyone bother me? We’re all in the Army together,” I replied.

He knowingly smiled. “Well, just in case.”

He was the NCOIC (non-commissioned officer in charge) of the Battalion S-2 (they handle Intelligence). I had been assigned to the Battalion S-3 (training and the Tactical Operations Center (TOC)). Our sections worked very closely, and we usually shared the same tents. Whenever I could, I spent time with him in his section or when he hung around the TOC.

When he wasn’t serving in the Army, Greg taught middle school math in Easton, PA. He talked about his students, other teachers, and gave me an entertaining view of what the job was like.

It seemed liked we were always in the field. We camped when it was 30 degrees and when it was 100 degrees. The food was awful. The tents were loud and musty. People got up early. To this day, I’m pretty much ruined for camping. Greg would entertain me with his life’s wisdom. He told funny stories. He would bring a piece of carpet and a coffee pot into the field. The carpet was for his feet in the morning and the coffee was for all of us. “Creature comforts, Frankie, creature comforts. It makes all of this easier. Don’t forget it.”

I haven’t.

Eventually, I ran into problems with other soldiers. Sometimes it was busy body NCOs, other times it was officious officers. I occasionally brought some of it on myself, but usually it was those motherfuckers. Greg would step in. Calm things down. Later, he’d say, “Frankie, you can’t say stuff like that. You have to go with the flow sometimes.”

I would listen to him. You know why? Because he was smart and competent and funny and I knew he cared. He was a great leader.

By the time he retired, he had been an E-8 for 18 years. Years before I joined, he had been the First Sergeant (1SG) of Headquarters Company (HHC). Everyone told me that he was the best 1SG they ever had. He took a lateral assignment as a Master Sergeant (same rank, but he was in charge of six people rather than 150). Whenever we got a new company commander, they inevitably went to Greg and would ask him to move back to the 1SG role. He would say, “I’ll do it if you let me kick out 10 people. We have a truck driver that can’t drive because of his DWIs. We have all kinds of people that shouldn’t be here.” The Captains always said no, because our unit was always below strength (not enough people). Later, he would tell me, “I can be in charge of you or 150 people. Being in charge of you is a better job.”

The first photo is from November of 2001. Our unit had been activated after 9/11. Our Battalion was assigned to monitor and guard the Hudson River Crossings (the GW, Lincoln Tunnel, Holland Tunnel and Journal Square in Jersey City). The command center was back in Port Murray. I was tasked around the other crossings for part of it, but I got to spend some time at the command center. Greg was in charge of one of the 12-hour shifts. Being in the TOC exposes you to everything the unit does and the high ranking officers. When VIPs visit, they usually come to the TOC first. Greg was doing such a bang-up job that a colonel came by and pretended to pin an officer rank on him. I insisted on capturing it with a photo. It shows his good humor.

Don’t be mistaken though. He could rip people apart. When he was in Cuba in 2004, he was in charge of a Joint Task Force full of Sailors, Airmen and Marines. I heard stories. One time, an E-6 in the Navy gave him some shit about a task and Greg ordered his superior to stand before him at 0600 the next day. Greg tore into him. The Chief Petty Officer was aghast and promised that his sailor would cause no further problems. A Marine colonel heard all of this and came in after the the ass chewing was over. “Jesus, I have never heard anyone rip into people like you. What I don’t get is that everyone still loves you.”

It’s easy. Because he was smart and competent and funny and everyone knew he cared.

Don’t worry. He’s still alive. This ends well.

I drove out to Easton, PA to see him today (9/11/18). We got lunch. I updated him about my life. We talked about other soldiers and what happened to everyone. We commiserated over the fallen and for those whose families fell apart. We also told jokes and laughed. At one point, Greg looked at me and said, “It’s great that you don’t have your cell phone out on the table. Everywhere I go, people are on those fucking things.”

“I know. Then they wonder why they are isolated and feel bad. Our culture is so fucked up that I’m going to be able to work forever. This is why I drove out here. To talk in person. Nothing beats that.”

Then we moved on to other stories. I let out my full throated cackle.

“There it is,” he said, “There’s that crazy laugh.”

28Aug/18

An Easy Fix for Addiction Hotlines

by Andrew Walsh

 

A few months ago I was invited to speak to a class of students at Rutgers in the addiction certificate training (ACT) program at the Graduate School of Social Work. I shared my experiences from graduate school and working in the field of substance abuse. While I was with the students, I was prompted to share some of the writing and undercover work I have done in the field of substance abuse treatment.

For a year and a half, I did full-time work and full-time graduate school. While my schedule was hectic, I was able to compare what I was learning in the classroom with what I was experiencing in the field. I was horrified.

Under the guidance of Professor Greenagel, I set out to start documenting and writing about the ever widening gap between best practices and what was actually occurring in the substance abuse field. One of the first subjects I tackled was addiction hotlines. My previous piece on addiction hotlines can be accessed here.

I found that the majority of the hotlines ranged from negligent at best to operating illegally. One of the main takeaways from my undercover work with the addiction hotlines was the lack of consideration that people with Medicare, Medicaid, or no insurance received. When I posed as a 27 year old with insurance seeking substance abuse treatment I could not get my phone to stop ringing. However, when I posed as a 26 year old with seeking substance abuse treatment with Medicaid, I could not get a phone call to last more than three minutes.

I was thoroughly convinced that the horrors of the substance abuse field would cause some of the students to reconsider their career paths.  A few months passed and unexpectedly one of the students from the class contacted me. She posed a simple question that stopped me in my tracks. She asked

With state treatment facilities in a state of stagnation due to lack of beds for Medicaid, Medicare, and the indignant, how can private centers work to meet this need for people with Medicaid, Medicare, or no insurance?

I recognized that I left my previous work half-complete. I did a mournful job of illustrating and summarizing the problem but I did not provide any solutions.

I set out to remedy the situation and decided that I first needed to quantify the demand for substance abuse treatment among Medicaid recipients, Medicare recipients, and those with no insurance. After quantifying the demand, I then sought out to quantify the services available; i.e. where can these people go to get help. My work on the Medicare population can be seen here and the piece on the Medicaid population can be accessed here. The main takeaway was that the demand for substance abuse services for these populations far exceeds the supply.

I spent one year working in the call center of a psychiatric hospital. Working as an addictions triage specialist, I took anywhere from 50-100 calls a day from potential clients or their family members looking for substance abuse services. I was fortunate that Medicare was accepted for treatment at that psychiatric hospital. However, I still received dozens of daily calls for patients with Medicaid or no insurance seeking services. After I did some research, I began to end those conversations by saying, “We can’t provide services to you here but if you get a pen and paper I am happy to give you the name of the facilities that can and their phone numbers.”

Inevitably, the callers would express sincere gratitude with some variation of: “Thank you so much. I have been calling around everywhere but I couldn’t figure out who could help me.”

I hold advanced degrees, have a few years of direct practice experience with substance abusers, and am familiar with the majority of substance abuse providers in the tri-state area. All of my experience and research has made it possible for me to know which facilities accept Medicaid, Medicare, and those with no insurance.

When I reflect back on my work, education and directed research, I come to two clear conclusions:

  1. The demand far exceeds the supply of services for Medicaid, Medicare, and those with no insurance
  2. Services exist but substance abusers and their families get worn down trying to find the programs that will accept them

I am a social worker, which means I am an idealist. But I am also a pragmatist. Ideally, I would like to see an expansion of offerings for the Medicare, Medicaid and uninsured populations. Pragmatically, I know this will take a long time. Additionally, it is unrealistic to hold private facilities responsible for expanding services to those populations.

That written, I believe private treatment providers can help clients access the services that do exist. The best practice would be for these private entities to call the appropriate facilities with the client and do a warm hand-off to the appropriate party. Pragmatically I realize that this causes a significant burden on the private entities and will be met with significant opposition. The practice that will encounter the least resistance from the private treatment providers but still produce a significant effect is providing the clients they cannot treat with the names of the facilities that can help them. As my previous work has shown, these lists are relatively small and should not take more than two minutes to share with these clients.

While I am troubled by the fact that there are waiting lists for Medicaid, Medicare and those with no insurance, I am horrified that people cannot even find these facilities to get on the waiting list. Private treatment provider hotlines are often the first point of contact for many substance misusers and their families. Even if they cannot provide services directly to these clients, ethically they should refer the clients to the facilities that can provide the services. With people dying because they can’t even get on the waitlist to keep the flame of hope alive, treatment providers that fail to refer clients are in essence saying a life may be worth less than two minutes.

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Andrew Walsh a Master’s Degree in Social Work and a Master’s Degree in Human Resource Management from Rutgers. Prior to working in the behavioral health field, Andrew worked in the Gulf of Mexico oilfield as an internal business consultant focused on innovation and improving the efficiency of people, processes, and procedures. He eventually decided to return to NJ to practice innovation in the behavioral health field. In his free time, Andrew enjoys hiking, cooking, and reading.

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27Aug/18

The Five Ways You are Most Likely to Die

Thanos is not real. Therefor, you need not fret.

 

 

 

 

 

 

Every Thursday for many years, I’ve run a multi-family group in an addiction treatment center for young adults and their families. Last summer, I wrote this list on the board and asked them to guess its significance:

  • Car crash
  • Hiking
  • Shoveling snow
  • Heart Attack
  • Cancer

People were dumbfounded and mostly had no response. I told them that these were the mostly likely ways that I would die (in no particular order). We’ll come back to that group. A few days later, I offered up the same list to my friends, parents, and my ex-wife. Only two friends got it right. My ex-wife figured it out after hearing just the first three.

One family member in the group exclaimed that it was a morbid topic. Another played into my hands by asking me how I arrived at that list. I explained to the group that I often drove above the speed limit and that there is a high correlation between speed and accidents. I discussed how I am hiking higher and higher mountains and have recently started hiking in winter conditions including deep snow and on sheets of ice. My driveway is over 100 feet long and opens into a large parking area – I shovel it alone and it often can take three or four hours. While I exercise and neither drink alcohol nor smoke cigarettes, I do have a diet high in red meat and I avoid vegetables. I have a sweet tooth and also smoke cigars. There is no known history in my family of cancer, but there is one for heart attacks. After explaining my list, I stated that I could lessen the chances of dying those ways by engaging in the following behavioral changes:

  • Drive slower. Never text or eat while driving.
  • If I’m taking a dangerous hike or going in extreme conditions, always have a guide or a partner.
  • Take breaks every half hour while shoveling snow. Don’t make speed a point of pride.
  • Eat a bit healthier. Lose some weight.
  • Eat a bit healthier. Reduce sugar intake. Cut down on cigars.

I have fully committed to items 2 and 3. I am slowly addressing items 1, 4, and 5 (ironically, those are the most likely ways I’ll die). I had every group member silently write down their list of the five ways they are most likely to die. Then I had them break up into smaller groups and share their lists. They were instructed to discuss what behavior changes they could attempt in order to reduce. After a half hour, I brought everyone back into a big circle. Their most common answers: drug overdose, car crash, cancer, heart attack, respiratory disease, and suicide. These are six of the ten ways that most Americans die (a note on the four group members who mentioned suicide – none of them had active suicidal ideations but they all had a history). The talk surrounding how to reduce these outcomes was lively and suggestions included: quit smoking, see a therapist, keep going to 12-step meetings, stop texting while driving, eat more vegetables, and take medication as prescribed.

Three other answers stood out. An older father listed diabetes. It developed from drinking and he has to monitor his blood daily, take insulin shots, and get regular medical checkups. Most of the clients did not know that heavy drinking could cause diabetes. A 2016 Cato Institute Study reported that diabetes is actually a top-ten killer of Americans.

Three people listed either “getting shot” or “getting killed.” They were clients in their 20s with long drug histories. One woman expressed fear about an ex-boyfriend who was currently incarcerated. I suggested talking to her counselor and a lawyer and to consider a restraining order. The two men who said they might “get shot” did not have a particular person in mind but each had dozens of friends who had either overdosed or were killed as a result of their lifestyle. Both agreed that remaining drug free and avoiding their home town greatly increased their life expectancy.

Three others listed “terrorist attack.” I addressed this issue from the flank. I wrote down the lifetime odds of Americans that die via falling (1 in 133), motorcycles (1 in 949), poison (1 in 1,355), fire (1 in 1,454), heatwave (1 in 10,745), and animal attacks (1 in 30,167). I wrote down the number of Americans killed in America by foreign born terrorists between 1975 and 2015. The Cato Institute reports the number is 3,024 and the lifetime odds are 1 in 45,808.  I asked the group why some people would be more concerned about terrorism, shark attacks and lightning strikes over problems caused by speeding, alcohol use, prescription drug abuse, smoking, and lack of exercise. A 23 year-old male who was five months clean replied, “We don’t want to acknowledge the problems that are our fault and have to make changes. It is easier to be afraid of things beyond are control and that are on tv a lot, like terrorists and shark week.”

It was the kind of statement that group therapists strive for – I couldn’t have put it better and it was much more impactful coming from him. There are a number of lessons here, and I would like readers to jot down their own list and discuss it with their friends and/or family members. And figure out what you can change so that you can live a little bit longer.

This could kill you

You might say that work or waiting is killing you, but that is almost certainly hyperbole

 

 

 

 

 

 

31Jul/18

Epigenetics and the Treatment of Substance Misuse Disorders

Danielle Victoriano interned at a non-profit mental health facility under the direction of Andrew Walsh. During some down time, she labored on a series of research projects and articles. This piece on Epigenetics is the second one to be published.

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In recent years, the growing number of substance abusers in the United States has become a topic of national discussion. As the death toll from overdoses continues to skyrocket—with about 63,600 deaths in 2016, a number 21% higher than in 2015—substance abusers, family members, substance abuse counselors, and scientists are desperately searching for solutions that would help curb this national crisis. From all this turmoil has arisen a potential aid in the fight against substance abuse: epigenetics.

The topic of epigenetics cannot be breached without a better understanding of DNA, the material inside cells that serves as the language of life. DNA is the command center for why we look the way we look, and sometimes, why we behave the way we behave.

DNA or deoxyribose nucleic acid can be broken down to four bases: Adenine, Thymine, Cytosine and Guanine. Each of these bases are attached to a phosphate group and a sugar, and this combination of bases, sugars, and phosphate groups form the double-helix ladder that often comes to mind when we think about DNA.

Image result for dna

However, this viewpoint is wholly incomplete. It must be understood that the DNA ladder also actually wraps itself around proteins called histones.  The tightness from the wounding around these histone proteins regulate which parts of the gene are expressed and repressed. The closer the histone proteins are to each other, the tighter the DNA is wound, and thus, the harder it is for the DNA-encoding machinery to access the DNA material. The further away the histone proteins are to each other, the looser the DNA is wound, which means that it is easier for gene expression to occur.

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The distance by which histone proteins are from each other and the tightness of the DNA wounding around these proteins is determined by two chemical groups. Attachments of methyl groups on either the DNA itself or on the histone proteins are associated with repressing, or turning off the expression of a gene, while acetyl groups are associated with expression, or turning on the expression of a gene. Methylating the DNA and/or methylating the histone proteins tightens up the DNA-protein interaction, while acetylating the histone proteins opens up the gene and allows for expression.

To think about it more simply, imagine a flashlight that’s been turned on. Now, imagine a hand covering it. To open up the fingers over the flashlight means that light will pass through. To close the fingers over the flashlight means that light will not be able to pass through. This is similar to how epigenetic modifications to the human genome works. The light represents the fact that the DNA material will be there, it is whether or not the hand is open or closed that will factor in to if the gene is actually repressed or expressed. When the hand is open, there is expression, and when the hand is closed, there is repression.

Thus, epigenetics is the study of how the human genome is modified not through changes in the base pair sequence, but how the structure of DNA and protein is modified through attachments of chemical groups that alter the configuration.

The blossoming field of epigenetics has paved the way to discovery of epigenetic markers brought by substance abuse. By epigenetic markers, this means that genes have been identified to be methylated or acetylated differently from the norm.

One substance misuse disorder that is of high importance to public policy is the abuse of opiates. According to the Center for Disease Control, in 2016, around 66% of the 63,600 drug-overdose related deaths involved opioid use.

Researchers have found that in opioid addictive patients, there is more expression of a certain neuro-excitatory gene, GRA1, that would account for the addiction’s withdrawal symptoms such as restlessness, muscle twitching, and dilated pupils. This overexpression can be attributed to hyperacetylation of the neuro-excitatory gene. Hyperacetylation means that the gene is constantly being expressed, which leads to more expression than usual.

Alcohol is yet another substance misuse disorder that has been identified to have epigenetic markers. With alcohol use, researchers have found dysregulated amount of protein factors in the brain through abnormal methylation and acetylation patterns in some genes. In turn, during the active influence of alcohol, there is high concentration of the protein Arc, which is associated with decreased levels of anxiety and stress. This relationship results in alcohol-dependence to combat negative emotions that can be seen in many individuals with alcohol misuse disorders.

Knowing the existence of these epigenetic markers, and being able to identify and locate where they are in the human genome opens up a whole new realm of opportunity in terms of treatment options in substance abuse recovery. Potentially, the current rates of relapse that follow inpatient detoxification treatments could be curbed. As of 2015, it is reported that more than 85% of substance misuse patients relapse and return to substance use within a year following treatment. Since withdrawal symptoms are a trigger for relapse, imagine being able to control and limit those symptoms by targeting the epigenetic markers that caused the symptoms in the first place. Imagine being able to de-acetylate the neuro-excitatory gene, GRA1, that is constituently turned on in those with opioid abuse. This would most likely make early recovery easier, less painful, and less daunting.

Medications that are currently being examined to combat substance abuse are histone deacetylase inhibitors (HDAC inhibitors) and DNA methylation inhibitors (DNMT inhibitors).  These medications would attempt to re-regulate the imbalance that have been produced by epigenetic modifications in the body, by reversing or inhibiting the effects of methyl groups and acetyl groups.

Though research is still in its infancy, with no current research on how these medications affect humans, results have shown to be promising. One research study looked at the effects of having histone deacetylase inhibitors in rats with alcohol addiction and found that with HDAC medication, these rats are less likely to seek out or self-administer alcohol.

In terms of non-medication related treatments, there has been a promising finding that exercise can be used to reverse some of the epigenetic modifications made from chronic alcohol abuse. It has been found through rat studies that exercise has restored the brain physiology that has been altered by chronic drinking. Alcohol-addicted mice that were treated with regular exercise had improved memories and brain activities when compared to the non-treatment group.

Despite these success stories in controlled environments, there is still a lot more that needs to be done before this new technology can be used in humans. Currently, we simply do not have the technology to selectively choose genes that are specifically targeted by different addictive stimuli. However, we are hopeful that this new field will take off. With growing interest from research institutes in the national and global arenas, we can hope that the awaited future of epigenetics is not that far.

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Danielle Victoriano is a member of the Princeton University Class of 2019. She studies Ecology & Evolutionary Biology and plans on going to Medical School. She can be reached at dzv@princeton.edu

 

30Jul/18

Epigenetics

Daniel Shen interned at a non-profit mental health facility under the direction of Andrew Walsh. During some down time, he labored on a series of research projects and articles. This piece on Epigenetics is the first one to be published.

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The National Suicide Prevention Lifeline is a 24-hour suicide prevention network that takes 1.5 million calls per year nationally, or roughly 4,000 calls per day[1]. Following the tragic deaths of celebrities Kate Spade and Anthony Bourdain earlier this June, this number rose by 65% for several days, an increase of more than 2,500 calls per day[2]. Such spikes are typical following media coverage of celebrity suicides; similar statistics were reported after musician Chester Bennington’s death in 2017, and in the months following actor Robin Williams’s death in 2014, national suicide morbidity rates increased by nearly 10% according to a recent study from Columbia University[3].

Regardless of the precise psychological and sociological factors behind the so-called “celebrity-suicide effect”, clearly these high-profile incidents seem to touch a painful hidden nerve within our nation. According to the National Institute of Mental Health, one fifth of all Americans, or nearly 45 million individuals, are currently struggling with some form of mental illness[4]. When news of Ms. Spade and Mr. Bourdain’s deaths broke, conversation within the media focused particularly on an alarming CDC statistic reporting a 30% increase in the national suicide rate since 1999[5]. (For reference, the national population grew by only 16% since then[6].) Yet despite the prevalence and severity of these illnesses, nearly 60% of suffering adults do not seek treatment, and if the caller volume spikes following Ms. Spade and Mr. Bourdain’s deaths are any indicator, this statistic likely suffers from under-reporting[7]. The minority that do seek treatment are nearly always prescribed medications that often come with a litany of adverse side effects – nausea, drowsiness, weight gain, and muscle tremors, to name a few – that add further stress to an already difficult situation.

Epigenetics is a growing area of biological research which has rapidly gained the attention of medical researchers within the past two decades and is now being considered as a potential strategy for devising effective psychiatric treatments. Promising developments have already begun in other arenas; recently elucidated epigenetic mechanisms behind some cancers have already led to the creation of novel cancer drugs, and similar progress is being made for many other non-communicable diseases[8].

In basic terms, epigenetics can be defined as the study of the biological mechanisms behind gene expression – that is, how cells can switch certain segments of DNA on or off in order to perform specific functions. For instance, although your skin cells and brain cells all contain the same DNA and thereby the same genes, your skin cells do not sprout dendrites and your brain cells do not secrete oils/sweat because both cell types have switched off the gene segments encoding for inappropriate and unnecessary features. Proper gene expression is essential for an organism’s growth and survival, and many diseases are the result of switches being in the improper state: some gene is turned off when it should be on, or vice versa. For example, many cancers arise when genes encoding for crucial DNA repair/proofreading proteins become switched off, leaving cells more vulnerable to cancer-causing mutations. This leaves medical researchers with a tantalizing prospect: if the onset of a certain disease is due to improperly switching on/off certain genes, could treatment simply be a matter of reversing the switches back to normal?

Psychiatric epigenetics research is based on the hypothesis that psychiatric disorders such as major depressive disorder (MDD) and schizophrenia have epigenetic markers – that is, these diseases are the result of either overexpression or underexpression of certain genes within brain cells, resulting in altered brain activity and behavioral symptoms. Furthermore, these markers can be either hereditary or environmentally triggered, and by reversing the pathological gene switches back to normal, the disease can be mitigated. Encouraging findings from cancer research and other non-psychiatric disciplines have already shown this to be a promising hypothesis8. MDD, schizophrenia, and generalized anxiety disorder (GAD) rank among the most common mental disorders in America, and consequently have been of primary interest for epigeneticists searching for markers[9]. Due to the sheer complexity of the brain, progress has been slower in the psychiatric realm compared to non-psychiatric arenas, as evidenced by the relative dearth of literature on the topic. Nevertheless, studies from animal models and post-mortem tissue studies have already yielded encouraging results; a few of these studies are highlighted below.

Major depressive disorder

Several lines of evidence have implicated brain-derived neurotrophic factor (BDNF), a protein responsible for healthy neuron function, as a key factor in the onset of MDD, with decreased expression of BDNF in the hippocampus being associated with depressive symptoms[10]. In 2009, a team from the University of Alabama used rat models to investigate whether or not the gene encoding for BDNF experienced any epigenetic alterations in depressed individuals[11]. They did so by subjecting a group of rat pups to abusive conditions such as social deprivation and maternal maltreatment to induce depressive behavior, then comparing their brain cells with those of a control group. What they found was that in the depressed rats, the BDNF gene exhibited signs of increased DNA methylation, a chemical modification of DNA that acts as an off-switch for gene expression. Furthermore, experimental treatments with a DNA methylation inhibitor, designed to undo this chemical modification, yielded promising results. Crucially, this epigenetic marker appeared to be heritable between generations as well: when female individuals from the depressed rat group were allowed to mate, their offspring also exhibited the same methylation patterns and the same behavioral symptoms. This suggests that epigenetics may offer a sobering framework by which the long-known hereditary aspects of mental illness can be understood.

Schizophrenia

 γ-aminobutyric acid, or GABA, is a neurotransmitter responsible for reducing neuronal excitability in the brain, among other functions. It has been hypothesized that for individuals suffering from schizophrenia, the mechanisms driving GABA production are defective in certain neurons, resulting in increased neural activity and pathological behavioral symptoms[12]. In 2005, a team of Harvard researchers looked for markers at the RELN gene within GABA-producing neurons, hypothesizing that defects in RELN production are a major factor behind GABA deficiencies[13]. Comparing post-mortem brain tissue between schizophrenic and non-schizophrenic individuals, they indeed found evidence of DNA methylation – an epigenetic off-switch – at this gene within brain cells of the frontal lobe in the schizophrenic samples. Moreover, their results were consistent with a previous study examining RELN expression in patients with bipolar disorder[14]. Given the similarity of psychosis symptoms between these two illnesses, this link suggests that epigenetics may provide a window by which the mechanisms behind these diseases can be better understood, leading to more effective treatments for a multitude of conditions.

Anxiety disorders

The hypothalamic-pituitary-adrenal (HPA) axis is a complex system consisting of the hypothalamus, pituitary gland, and adrenal glands and can be thought of as the “stress-system” of the body, forming the link between brain activity and hormone production. Corticotropin-releasing hormone receptor 1 (CRHR1) is a crucial protein that contributes to activating our bodies’ stress response via this system. A recent 2016 study from the Weizmann Institute of Science in Israel used rat models to investigate whether or not the gene encoding for CRHR1 was affected in rats with anxiety disorders (induced through various means)[15]. They found that for anxious rats, the CRHR1 gene was under-methylated compared to healthy rats, suggesting that this protein was being overexpressed in anxious individuals and resulting in overactivation of the stress response. When they treated the anxious mice with an experimental drug designed to restore methylation, they found that many of their symptoms subsided, demonstrating that epigenetics can indeed be a promising avenue for designing new pharmacological therapies.

Next steps

The above studies all present a positive correlation between specific epigenetic signatures and the onset of psychiatric disorders, suggesting that epigenetics research is indeed a promising direction for future diagnosis and treatment methods for these disorders. Nevertheless, the field of psychiatric epigenetics is still very much in its infancy, as evidenced by the relative dearth of literature on the subject compared to other disease studies like cancer. Moreover, all of the drugs that have been developed thus far (including the cancer drugs), promising though they may be, have been pan-inhibitors – that is, they affect the entire genome rather than specifically targeting one gene, raising concerns about potentially dangerous side-effects that are not fully understood. Reaching the point where epigenetic treatments can act with specificity and accuracy on single genes requires a more extensive understanding of our cells’ epigenetic mechanisms in all of their complexity, which is beyond our current knowledge. Given that our cells regularly erase and re-write epigenetic markers on their own as part of normal functioning, elucidating these mechanisms is certainly possible, and the moment we gain the ability to selectively modify epigenetic markers on single genes will herald a paradigm shift in medicine and human history.

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Daniel S. Shen is a member of the Princeton University Class of 2019 and studies within the Department of Music. He is planning on going to Medical School. He can be reached at dsshen@princeton.edu

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[1] Draper, J. (2015, January 05). National Suicide Prevention Lifeline: The First Ten Years. Retrieved July 05, 2018, from https://www.sprc.org/news/national-suicide-prevention-lifeline-first-ten-years

[2] Ravitz, J. (2018, June 13). Calls to suicide prevention hotline spiked after celebrity deaths, but what’s the next step? CNN. Retrieved July 5, 2018, from https://www.cnn.com/2018/06/12/health/suicide-hotline-increase/index.html

[3] Fink DS, Santaella-Tenorio J, Keyes KM (2018). Increase in suicides the months after the death of Robin Williams in the US. PLoS ONE 13 (2): e0191405. https://doi.org/10.1371/journal. pone.0191405

[4] Mental Illness. (n.d.). Retrieved July 05, 2018, from https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

[5] Stone DM, Simon TR, Fowler KA, et al (2015). Vital Signs: Trends in State Suicide Rates — United States, 1999–2016 and Circumstances Contributing to Suicide — 27 States. MMWR Morb Mortal Wkly Rep 2018;67:617–624. DOI: http://dx.doi.org/10.15585/mmwr.mm6722a1.

[6] Population data retrieved July 5, 2018, from https://data.worldbank.org.

[7] Substance Abuse and Mental Health Services Administration, Racial/Ethnic Differences in Mental Health Service Use among Adults. HHS Publication No. SMA-15-4906. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. Retrieved July 5, 2018, from https://www.samhsa.gov/data/sites/default/files/MHServicesUseAmongAdults/MH

[8] Allis, C., & Jenuwein, T. (2016). The molecular hallmarks of epigenetic control. Nature Reviews Genetics. http://dx.doi.org/10.1038/nrg.2016.59

[9] U.S. DALYs Contributed by Mental and Behavioral Disorders. (n.d.). Retrieved July 6, 2018, from https://www.nimh.nih.gov/health/statistics/disability/us-dalys-contributed-by-mental-and-behavioral-disorders.shtml

[10] Castren E, Rantamaki T. The role of BDNF and its receptors in depression and antidepressant drug action: Reactivation of develop- mental plasticity. Dev Neurobiol 2010;70:289–97.

[11] Roth TL, Lubin FD, Funk AJ, Sweatt JD. Lasting epigenetic influence of early-life adversity on the BDNF gene. Biol Psychiatry 2009; 65:760 – 769.

[12] Costa E, Chen Y, Davis J, Dong E, Noh JS, Tremolizzo L et al. REELIN and schizophrenia: a disease at the interface of the genome and the epigenome. Mol Interv 2002;2:47–57.

[13] Abdolmaleky HM, Cheng KH, Russo A, Smith CL, Faraone SV, Wilcox M et al. Hypermethylation of the reelin (RELN) promoter in the brain of schizophrenic patients: a preliminary report. Am J Med Genet B Neuropsychiatr Genet 2005;134B:60–6.

[14] Fatemi SH, Earle JA, McMenomy T. 2000. Reduction in Reelin immunor- eactivity in hippocampus of subjects with schizophrenia, bipolar disorder and major depression. Mol Psychiatry 5:654–663, 571.

[15] Evan Elliott, Sharon Manashirov, Raaya Zwang, Shosh Gil, Michael Tsoory, Yair Shemesh, Alon Chen. Dnmt3a in the Medial Prefrontal Cortex Regulates Anxiety-Like Behavior in Adult Mice. Journal of Neuroscience 20 January 2016, 36 (3) 730-740.