Author: Maria Yang, MD

Categories
COVID-19 Nonfiction Policy Public health psychiatry Reading

Public Mental Health Implementation Failure.

Throughout the pandemic, I have routinely reviewed the major psychiatric journals in the United States, hoping for commentary about and guidance related to the prevention or minimization of psychiatric conditions due to the Covid-19 pandemic. Surely there are practices or protocols we could implement to prevent bad outcomes that we knew would happen! While the work we do with individuals might have some potential benefit, the scale of the pandemic meant that population-level interventions would have better effects for a greater number of people. From my point of view, if my finite time and energy could help more than the sole person in front of me, that would be better for all involved.

Three thousand years ago, back in December 2020, I commented that “collective problems require collective solutions; expertise must be decentralized and shared” while reflecting on the need to Protect Mental Health During a Pandemic. Now that three thousand years have passed, it seems that anyone at the federal level who tried to implement the Pan American Health Organization or World Health Organization recommendations from the flu or ebola epidemics was foiled. I lamented then that

We’ve already witnessed psychological stumbling across the population; none of us want to see ourselves, our neighbors, our communities, and those beyond beyond fall further.

We’ve graduated to chronic psychological lurching, floundering, and tottering. Most of the psychiatry journal articles have only described consequences from the current pandemic: who was more likely to get Covid-19? how did it affect the use of substances? how was the pandemic affecting the workforce?

Where were the articles with broad vision, that take the perspective of public health psychiatry?

The Lancet Psychiatry recently published an article that I found refreshing: Public mental health: required actions to address implementation failure in the context of COVID-19:

  1. It acknowledges how the mental health system—one of many—has failed during the pandemic (people may have opinions about whether it was succeeding prior to the pandemic);
  2. It lists specific failures and how to fix these problems (and there are a lot of problems to fix);
  3. It reinforced the need to direct attention and resources to all stages of the lifespan and the various roles, from individuals to national governments, each could play to prevent future failure.

The authors rightly comment

This failure of [public mental health] implementation results in population-scale preventable suffering of individuals and their families, a broad range of impacts…, and large economic costs. The failure also represents a breach of values and the right to health.

Panel 5 lays out how the implementation failures of public mental health:

  1. Insufficient public mental health knowledge
  2. Insufficient mental health policy or policy implementation
  3. Insufficient resources
  4. Insufficient political will
  5. Political nature of some [public mental health] activities
  6. Insufficient appreciation of cultural differences
  7. Causes of mental disorder treatment gap

Oof. It’s a valid list and, indeed, some of the responsibility falls upon mental health and substance use disorder clinicians ourselves. (Different posts for different days.) It’s also striking that, despite the United States being a high income country, we suffer from the same problems listed above that apply to low income countries. (We, however, continue to learn the many ways how the US was and is never different from “those” low income countries.)

As I noted a few weeks ago, “We continue to focus on the viral pandemic; the psychological pandemic has already arrived.” Because of our missteps, the psychological pandemic will also outlast the viral pandemic. The authors note that

The COVID-19 pandemic has widened the implementation gap but has also increased mental health awareness and highlighted the need for a [public mental health] approach.

Now that we are minding the gap, I hope that we can indeed close it.

Categories
Homelessness Nonfiction Policy Public health psychiatry Seattle

Shelter “Isolation” and “Quarantine”.

Though the room layout follows pandemic guidance, it still feels crowded.

Dozens of beds are placed six feet apart. In a homeless shelter, each twin mattress is multipurpose furniture: Yes, it is a bed where people sleep. It is also a table upon which they eat simple meals stuffed into brown paper bags. It is a living space of 38 by 75 inches that offers no privacy and no isolation.

Say someone living in the shelter falls ill with Covid. Should this person be allowed to stay in the shelter, but risk infecting others? Or should the shelter ask this person to leave and recover in the chill and darkness of January?

Seattle-King County has been a leader in implementing isolation and quarantine (I&Q) sites for people who don’t have their own place to live. These are hotels that allow people who were exposed to or infected with Covid-19 to rest and recover away from others. The hotels have specialty staff who provide physical and behavioral health care. Once recovered, people can return to shelter or similar congregate settings. It is difficult to prove the success of prevention, though removing people from congregate settings likely reduced infections. This, in turn, reduced hospitalizations and deaths.

Last winter, there were four I&Q sites. This winter, there are only two.

This reduction isn’t for lack of need. As with the general population, the omicron variant has caused a crush of infections in shelters. The I&Q sites, like most health care agencies, cannot hire enough people to provide services. This reduction in I&Q sites is entirely due to an insufficient number of staff.

Because fewer health care workers now work at the I&Q sites, the county has had to enact more exclusion criteria to preserve this service. Providing support for people with multiple health conditions requires professionals with expertise and experience; physical space and supplies are not the only considerations.

This means that people living in shelters who are ill with Covid will be denied admission to I&Q sites.

That means that people who are sick with Covid may only have bad options to choose from. If they’re lucky, they may be able to stay in a shelter. However, their living space of 38 by 75 inches has no walls. Sights, sounds, and air are all shared.

The average age of someone experiencing homelessness for the first time is now 50 years old. People who live in shelters, cars, or outside are more likely to have chronic health conditions like high blood pressure, diabetes, depression, and anxiety. These conditions are risk factors can result in more severe cases of Covid illness. These same factors also increase the risk of disease and death if people are sent outside.

With the attrition of health care and essential workers, the burden of illness and disease will fall upon the most vulnerable people in our communities.

This also means that staff who are still able and willing to work at the shelters–all essential workers–are at increased risk. Most shelters do not have access to medical expertise or consultation. If there is nowhere to send people who are ill with Covid, shelter workers will have to decide what to do if someone in the shelter gets sick. We cannot expect all shelter staff to have the skills, knowledge, and desire to provide isolation and quarantine support. If shelter workers send someone out, that will only put more burden on the safety net of first responders and emergency departments. This safety net is already fraying and breaking after two years of crisis.

Systems cannot rely on single individuals, though this has been happening more and more as the pandemic has dragged on. As various systems falter and crumble, we see the demoralization and exhaustion of all who provide essential services. More distressing are the detrimental effects these system failures have on vulnerable people we want to serve well, but cannot.

This is unfair to all involved. Inside and outside of the crowded room of the shelter, it is with horror that we realize that all of our options are bad.

Categories
COVID-19 Homelessness Nonfiction Public health psychiatry Seattle Systems

Faltering and Failing.

The omicron variant has resulted in a surge of cases here in Seattle-King County:

Our hospitals have not been spared. They, like in other areas, are in a crisis situation:

There are similar surges in Covid cases in homeless shelters and other congregate settings. This, combined with an insufficient number of people who are willing and able to work at isolation and quarantine (I&Q) sites, has led the I&Q sites to limit the number of admissions. The admission criteria now are the most stringent they have been at any point during the pandemic:

What this means in practice is that people living in shelters who are sick with Covid may have nowhere else to go. If they are lucky, they will be able to stay in the shelter. Their only other option may be staying outside in the chill and darkness of January.

Which is worse? Covid infections sweeping through a homeless shelter? Or people exiled outside because they are sick? (They may end up seeking help at an emergency department, all of which are already strained and overburdened.)

To be clear, I do not blame the county for this. Health care workers are fleeing their jobs due to the crush of the pandemic. Everyone is struggling with hiring health care and essential workers.

We cannot look away from the horror of systems faltering and failing. We must witness that the most vulnerable people in our community will bear the greatest brunt of these failures.

Categories
COVID-19 Education Public health psychiatry

Reactions and Behavioral Health Symptoms in Disasters.

The Washington State Department of Health started posting Behavioral Health Monthly Forecasts in April 2020. Two disaster psychologists, along with other staff, compile and share useful information such as the anticipated course of psychiatric symptoms across the population, how different populations might manifest their distress (e.g., children), and data related to changes in substance use and firearm purchases. It makes for interesting reading, though it’s frequently a bummer.

One chart that appears every month is “Reactions and Behavioral Health Symptoms in Disasters”. In the inaugural issue in April 2020, the forecast oriented readers to general model from SAMHSA[1. SAMHSA is the Substance Abuse and Mental Health Services Administration. What a shame that it is a distinct department from the Centers of Disease Control and Prevention (CDC). The mind remains split from the body in our administrative and health care systems, which is why there is no formal framework for public health psychiatry.] of reactions in disasters:

Note that there is no indicator here about where Washingtonians were at that time. The Y axis uses color to depict emotional states and the X axis, so optimistic, has only a notation to mark one year.

In May 2020, the forecast made a proclamation about where Washingtonians were. It was a warning: We were on the precipice of disillusionment:

We braced ourselves for this. Yes, we had witnessed heroism from so many, whether health care workers or first responders or neighbors dropping off food for those who were medically vulnerable or distilleries producing hand sanitizer or seamsters and seamstresses joining brigades to make cloth masks. Of course this level of concern and anxiety was unsustainable. How bad could it get?

Well.

By December 2020, we were in a trough of disillusionment and it felt like it:

Thousands of people were dying a day in the US and other countries around the world. Hospitals were overrun with sick people. People were starting to leave their jobs due to overwhelm. When would the vaccines become available? I remember looking at this graph and thinking, “I thought the graph last month had us in the nadir of disillusionment.” But there was a branching of lines! Maybe we, as a state, would follow the yellow line and things would improve for us all, regardless of station in life.

Well.

A terrible winter passed. The days got longer, there were more opportunities to be outside, many people got vaccinated… but the yellow line never manifested for those in my professional and personal communities. By June 2021, we were still in a trough:

In retrospect, that “secondary honeymoon” was accurate. All the numbers we hoped would drop, did: Reproductive number, cases, hospitalizations, and deaths. People in the Seattle-King County area were getting vaccinated. But so many of the people under our care were dying from overdoses, suicide, and chronic medical diseases.

Then came Delta, Omicron, more cases, hospitalizations, and deaths. Health care workers and others left their jobs out of frustration and demoralization. A contingent of people continued to decline vaccinations, despite knowing the possible outcomes… including chronic disease and impairment that still has no effective treatment.

When the December 2021 graph came out, someone observed, “The trough just keeps getting longer.” I wondered who on Earth was experiencing the benefits of “reconstruction”.

I have never had so many people under my care die during a comparable period of time. At least 10 of my patients have died since the beginning of the pandemic; the first death occurred in July 2020. The most recent death (that I am aware of) happened in November 2021. None of these people died from Covid. They either died by suicide, overdose, or their chronic illness collided with an acute, fatal event.

We know from history that pandemics do not last forever. The 1918 flu pandemic lasted just over two years. The 2002 SARS outbreak was declared over in less than two years. The 2013 Ebola epidemic persisted for less than three years. All things change, all things end.

I, like so many others, hope that we all will exit this trough sooner than we anticipate. I worry about the psychological consequences of this pandemic in the years to come. We continue to focus on the viral pandemic; the psychological pandemic has already arrived. We have yet to see an organized response to that.

Categories
COVID-19 Education Nonfiction

The Pandemic and DBT Skills.

If you look at my archives, you can tell when the burden of the pandemic (whether due to the pandemic itself or the consequences of it) became great: Weeks or months went by without a post. This doesn’t mean I stopped writing; I just stopped posting. Though it is true that some writing (i.e., ranting, rambling) is better kept private, my lack of posting was chiefly due to fatigue. One must think about something to write about something and, you know, I, along with everyone else, am tired and cognitively impaired.

While walking along the still waters of Lake Washington with a friend recently, we reflected on the endless opportunities to practice dialectical behavior therapy (DBT) skills throughout the pandemic. I had the good fortune to learn about and practice DBT for a full year of my psychiatry residency training; I also led the DBT skills training group. As such, I taught the skills to myself over and over again (as that, for me, is the only way I feel comfortable teaching these skills to other people). To the group I often said, “I use these skills all the time.” They may have thought I was telling a white lie, though I was not: I used them all the time and continue to use them now.

Mindfulness. In DBT, this refers to paying attention, without judgment, to what’s happening right now. (See “Right now, it’s like this.”) When we give our attention to what is happening right now, we can witness the events that are (or are not) happening, our reactions to those events, and other “things” we might be adding to the situation. (Our minds are miraculous thought-generating machines, just as our hearts are amazing pumpers of blood. That’s just what they do.) We cannot take next steps if we don’t know what’s happening right now. For example, if a friend is trying to give you directions, but you have no idea where you are, you and your friend will have a hard time finding each other.

The underlying dialectic in DBT is acceptance versus change. If you don’t accept that you don’t know where you are, you cannot change. If I insist that I’m in Los Angeles, even though I’m actually in Seattle, then I am in for a lot of suffering as I try to get to Diddy Riese Cookies by public transport. It is only when I accept that I’m in Seattle that I change and, instead, go to Hello Robin Cookies.

Yes, it’s hard to give our attention to the pandemic and the illness and deaths it has caused, American politics and the ensuing vitriol, and the suffering that both (and other events) have wrought. Acceptance doesn’t mean agreement. Without acceptance, we cannot take next steps.

Distress tolerance. The acceptance described above is a form of distress tolerance (and, in DBT parlance, is called “radical acceptance”). Distress is difficult to tolerate; who among us wants to feel distressed? Wouldn’t you rather feel serene or joyful? Sometimes we worry that the distress will overwhelm us, that the shame or anger will consume us and never go away. Distress tolerance involves mindfulness to attend to what is happening right now, accepting that right now, it’s like this, and then choosing how to cope with the current reality. (See Viktor Frankl’s comment about the space between stimulus and response.) We can’t evade distress. We can choose how we respond to it.

Last winter, one strategy I used to manage my distress was eating a lot of carbohydrates: Pizza, burgers, noodles, dumplings, and my beloved cookies. I understand why I chose that strategy (and it’s one I still fall into on occasion), but it’s not one I want to repeat this year (largely because it didn’t actually reduce my distress much). Oddly enough, the distress feels less acute and piercing this year, perhaps because it is impossible to maintain those physiological and psychological levels of stress for a prolonged period of time. It may also be that I have come to embrace that yes, we all can die at any moment and, thus, we must enjoy all the little things that are lovely while they are happening.

Interpersonal effectiveness. When we don’t feel at our best, our communication and interactions with other people can sour. Not even because we want to come across as aloof or jerky; it just takes energy and mindfulness to assert ourselves and maintain harmonious relationships. Often interpersonal effectiveness skills focus on asking for what you want, managing perceived (and sometimes real) conflict, and boundaries.

If I am alone when I learn of new Covid cases at work, it is not uncommon for me to groan and mumble words that may or may not be profane. Sharing such sentiments with colleagues, though, isn’t helpful and doesn’t increase my effectiveness. Crabbiness generally isn’t charming. Assertiveness scripts or nonviolent communication templates may seem unnatural, though, with practice and personal tailoring, help all of us get along when we’re all feeling tired and cranky.

Emotion regulation. Though internal and external voices may tell you otherwise, your emotions, regardless of what they are, are valid. You feel what you feel. There are, however, things we all can do to increase the likelihood that we will feel certain emotions. In 12-step groups, people often refer to “HALT”: Hungry, Angry, Lonely, and Tired. If we are already experiencing one of those four things, we are more likely to feel worse if another stressor comes our way. (Hence the value of eating and sleeping regularly, as well as building and sustaining community—whatever that may mean to you.) Naming emotions (with the help of mindfulness) is also a skill, as that helps us recognize that we are feeling an emotion, we are not actually the emotion. Emotions give us vital information, though sometimes we realize that there are no logical reasons that underlie how we feel. If I feel anxious because I believe I’m in the way, but I’m not actually in anyone’s way, then the task is to do the thing that will make me feel more anxious… so I eventually stop feeling anxiety due to thoughts about being in the way.

The duration of the pandemic and its consequences makes emotion regulation hard. We can try to reduce our vulnerabilities by eating, sleeping, and connecting with others as well as we can, though ongoing news of illness, death, conflict, and violence reduce our resilience. There are real problems in the systems we live in and under in the US. It is unfair and inaccurate to ask individuals to keep their chins up and “just be happy” when our current context is so abnormal. We, however, can still make choices in that space between stimulus and response.

I often quip (with decreasing levels of energy) that the pandemic is developing my character, though I’m ready to be done with personal growth. Right now, though, it is like this. We also know that everything changes. The pandemic will end (just not when we want it to), things will change (though perhaps not in the way that we anticipate), and many of us enjoy blessings right now that we take for granted (e.g., you are able to read these words! you have access to the internet! most, if not all, of you know where you will sleep tonight! you haven’t died from Covid!).

If you’d like to learn more about dialectical behavior therapy and the four skills above, this website is pretty good and covers the four core skills with plenty of examples.