Friday, April 04, 2014

Ivan Lopez: Could this have been prevented?

Ivan Lopez screenshot Facebook
Ivan Lopez shot 19 people yesterday, killing three at Fort Hood, Killeen, Texas. Five years ago, same army base, Nidal Hasan, an army physician, killed 13, wounded 33. Hasan has been sentenced to death.

Lopez served 4 months in Iraq in 2011 driving a truck, served in the Sinai Peninsula, too, and the National Guard. He's not been injured, officially, in combat. In fact the army claims he didn't serve in combat.

He either requested or was ordered a mental health evaluation, hence the transfer to Fort Hood from another base, according to one report.. His mother died of a heart attack in November last year, and the army gave him a hard time about going to Puerto Rico for the funeral. Granted a one day leave, he complained, was granted two. (Not much of a grief allowance, but typical in the military). The psychiatrist considered him nonviolent, prescribed Ambien for sleep. Follow-up in a month.

Perhaps Lopez forgot to tell the doctor. Somebody is going to pay for this. I need to be with my family.

One news bureau suggests that not only Ambien, but a variety of other psychotropic prescriptions were prescribed as well. Nothing unusual about that, to be expected, even, but one of those drugs could have been an SSRI, from a family of drugs that has saved millions, but is associated with suicide and bad decision-making.

Quick story:  About a month ago a new patient, referred by a physician, called me very depressed. In his fifties, I saw him the next day, and as is usually the case, he had a pocket list of the medications he's taking. One, an SSRI. Short list of those:

fluvoxamine maleate(Luvox),
paroxetine hydrochloride (Paxil)
citalopram (Celexa)
escitalopram (Lexapro),
fluoxetine (Prozac)
and Sertraline hydrochloride (Zoloft). 

Hearing his suicidal thoughts, I scheduled him for the next day, and then again the day after that. That or refer the patient directly to an emergency room for evaluation and hospitalization. My new patient wasn't ready for that but it is always Plan A.

Not being a medical doctor, when he told me about the SSRI, I thought nothing of it, assumed that perhaps he just needed more. I was going to call the referring physician, when FD popped into the room (a family doctor, happens to live with me). I picked his brain first, described a man in his fifties, suicidal thoughts, an SSRI. Could we up it?

He quickly replied, "Not the best choice, that family of drugs, for someone with suicidal thoughts. Can make suicidal people disinhibited."

What does that mean, disinhibited? I understand what it means in other contexts, but how does disinhibited manifest under prescription meds?

"Oh, they'll do things they might not ordinarily do. A person with suicidal or homicidal thoughts might be more inclined to act upon them on those drugs. That's why we keep them away, generally, from suicidal teenagers. They're already unpredictable."

Which leads me to an entirely different explanation, why Ivan Lopez gunned down innocent people at Fort Hood. His neighbors describe an amiable, friendly man, married to a friendly woman. Armed, as soldiers usually are, he acts upon impulses that seem out of character for friendly people. He is disinhibited, and this is what disinhibited people sometimes do.

The only other real consideration is his self-diagnosed traumatic brain injury. Brain trauma can change character, too, turns loving personalities into angry, violent people. But they are always angry and irritable and Lopez wasn't.

We can blame the meds, perhaps, but perhaps not. He had a Facebook page, an alias Ivan Slipknot. On that page he wrote in Spanish:

“The people shouldn’t fear the government — the government should fear the people.”

So perhaps it wasn't out of character, after all.

We might be wonder why the psychiatrist didn't make a followup for Lopez sooner. He had a month between visits.

I would venture to say that the facilities at Fort Hood are mobbed with psychiatric patients coming home from Iraq and that professionals are working night and day treating post traumatic stress. Suicide in the military is at an all-time high. It is likely that Spc. Lopez didn't express violent thoughts or plans, his dirty little secret. His knew what he was doing. But he felt lousy, so he asked for legitimate help, medication for sleep.

It has been five years since the last massacre on an army base, one that had the makings of a terrorist attack. We worry incessantly over those. Time to worry about our soldiers. Vet them a little more carefully in those evaluations.



Dawn Hurst-Stultz said...

this was a great article.
you are very insightful.
thank you.

Mound Builder said...

I was re-reading your article about this fellow who went on his rampage at Ft. Hood (my first thought was 'oh no, this can't be happening again') and thinking about the teen who went on the knifing rampage at his high school in Pennsylvania, wondering if that could have been somehow prevented. I've read only a little about the teen, found myself wondering if possibly his attack was the result of early onset schizophrenia, and if so, how important it is for young people and teachers, parents, everyone, to learn to recognize what it's like when someone may be experiencing psychotic symptoms/delusions. I keep thinking surely there is something the person lets slip, even if they are mostly trying to keep those symptoms hidden. Or maybe the person doesn't even quite realize something has gone awry in his/her own thinking.

What It Takes To Be Me said...

This is a really good post. It's odd how rarely patients are told of the potential side effects of SSRIs in terms of suicidal ideation and inhibition. I was once put on paroxetine (also an SSRI) and literally within a few hours of taking it I became acutely suicidal. I have never felt that out of control of my own actions (save when I was on fertility treatment, but that's a different story). I happen to have a father who is a psychotherapist and who had warn me that this might happen, so I had made sure my partner and friends were looking out for me, but it was still a frightening experience. I've since been told that because of this extreme (and thankfully reasonably rare) adverse reaction my GP and I know not to go near SSRIs, but prior to this my GP had said nothing about this potential side effect.

Also, just wanted to comment on the quote “People shouldn't be afraid of their government. Governments should be afraid of their people". This isn't necessarily a sign of a violent personality. This is a quote made popular by Alan Moore in his graphic novel "V For Vendetta" and is commonly used within Anonymous pseudo circles, in general to highlight the fact that people should have a voice and not be silenced by governments. Of course it is impossible to know if this is the meaning Lopez gleaned from it, but I just thought I'd offer that angle as an alternative perspective.


therapydoc said...

MB, totally. He was thought to be strange and should have been tested. At least seen someone to find out why. Dr. Drew was right on when he said on HLN, Morning Expess, "You see? It isn't all about the guns."

therapydoc said...

What it takes, i had no idea! Bet Lopez didn't either. Thanks!

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