Author: Maria Yang, MD

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COVID-19 Homelessness Medicine Seattle

Surge.

When I was younger, my intention was to become an infectious disease doctor. Forces, seen and unseen, pulled me into psychiatry.

My undergraduate studies were in microbiology, virology, and immunology. Had someone told me twenty years ago that I would someday use that knowledge on a daily basis, I would have shrugged and said, “Well, that makes sense. That’s the plan, right?”

Had someone told me ten years ago that I would use knowledge from my undergraduate studies during a pandemic, I would have snorted: “But now I work as a psychiatrist. And a pandemic? What are you talking about?”

Had someone told me two years ago that I, as a psychiatrist, would be leading a public health response for a homelessness services agency during a global pandemic, I would have furrowed my brow: “What are you talking about?”

And here we are.

We’ve never had so many people—staff and patients—test positive for Covid at one time during the pandemic as we have in the past three days. Thankfully, most have had only mild symptoms and none, thus far, have needed hospital-level care.

The work we’re doing for Covid isn’t as intense or heartbreaking as the work my colleagues are doing in emergency departments and hospitals. Never before had I thought that a homelessness services agency could play a vital role in prevention and early intervention.

And here we are.

Throughout the pandemic, our team has framed our efforts as one way to keep people out of emergency departments and hospitals. These could be our humble contribution to our colleagues working in inpatient settings. We have been largely successful, though I worry that our luck is running out.

We continue to witness the indirect effects of the pandemic. Some have been lethal: Suicides and overdoses, whether intentional or not. Some are worrisome: More irritability and increasing intolerance for the challenges and annoyances of life, regardless of one’s station. I wince when I consider what might come next as we witness this surge of cases.

God have mercy on us all.

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Reading

Other Things to Read.

Yes, I’ve been writing, though I don’t know what to say. So, instead, here are some items I’ve read recently that you may find interesting, too.

Do wild animals get PTSD? Scientists probe its evolutionary roots. (Knowable) “These findings add to a growing body of evidence showing that fearful experiences can have long-lasting effects on wildlife and suggesting that post-traumatic stress disorder, with its intrusive flashback memories, hypervigilance and anxiety, is part of an ancient, evolved response to danger.”

Walk as Spreadsheet. (Craig Mod) This inspired me to create a boba tea spreadsheet. I don’t indulge in boba tea often, though, so my spreadsheet has few entries.

Direct and Indirect Mental Health Consequences of the COVID-19 Pandemic Parallel Prior Pandemics. (America Journal of Public Health) “Failure to recognize that COVID-19 is among the infectious diseases that may directly cause psychiatric conditions has led some policymakers to incorrectly conclude that adverse mental health con- sequences of the pandemic are driven solely by mitigation, creating a false choice between COVID-19 containment and preserving mental health. Similarly, failure to appreciate that fear, bereavement, and pandemic-associated life disruption can have adverse mental health consequences could lead policymakers to allocate mental health resources only to those who have had SARS-CoV-2 infection.”

Why Some People in Chinatown Oppose a Museum Dedicated to Their Culture. (New York Times) “Bringing in too much aesthetic of a certain class means it will lose the authenticity, that feeling you get when you go there that you’re in someone’s community that is meaningful, and you’re being allowed to share that experience.”

Finding a Way Back from Suicide. (New Yorker) A journey of recovery through electroconvulsive therapy.

Meditating on Your Death Could Make You Happier. (Vice) “When faced with the reality of death, what seems important?”

Why We Can’t Wait (Martin Luther King, Jr.) and God-Level Knowledge Darts (Desus and Mero). An unusual, yet complementary pairing.

Categories
COVID-19 Nonfiction Public health psychiatry Seattle

God Help Us All.

It’s like watching something happen in slow motion, but there is somehow not enough time to stop what is happening.

I don’t know either emergency department medical director well, though we are friendly enough to send greetings a few times a year. We all already knew that hospitals across the state are over capacity. One wrote about the “brutal impacts” across the state due to the additional number of patients. And this precedes the anticipated “all time highs for Covid in about two weeks”. The other, more economical with his words, noted that his team is “maintaining”, but “that the recent surge is further stressing the teams”, adding to “moral injury”.

A friend who works for a third hospital system shared with me that an emergency department had to close down because there weren’t enough staff to operate the place. This emergency department is in a suburb, not a rural town.

It’s not just emergency departments. My colleagues in primary care are reporting that they have had more people under their care die in the past year. They’re not dying from Covid. They’re dying from chronic medical problems.

I myself have never had so many people under my care die in such a short amount of time. They, too, did not die from Covid. Instead, they died from suicide, overdoses, and chronic medical problems.

Like others, I’m watching the number of Covid cases soar. There was a time when daily deaths from Covid were only a few dozen. Now we’re somehow back in the hundreds.

During the late winter, when thousands of people were dying each day in the US from Covid, the grief would overcome me without warning. These days, I feel the mass of dread growing in my body. My chest caves in from the misshapen weight; my jaws are tight, as if they are holding back anguish that transcends words.

God help us all.

Categories
COVID-19 Nonfiction Policy Public health psychiatry Systems

Pandemic of Demoralization.

I haven’t posted much recently because I don’t want to be a bummer. There’s enough of that in the world right now: disasters on a global scale and quiet tragedies just down the block.

I worry about the health care workforce. While it is indeed a privilege to go to school to learn about illness and health and then apply those skills to people who somehow trust us, this pandemic has squeezed and stretched us in ways none of us could anticipate. Not only do we see people who get sick with Covid-19, but we also see all the people who get sick from everything else because of the system pressures and failures due to Covid-19.

I see the fatigue on my colleagues’ faces; I see their struggles in trying to provide the best care they can when they themselves are not thinking or feeling their best—now going on for over a year.

We all remain focused on the Covid pandemic, though the demoralization[1. “Demoralization is a feeling state of dejection, hopelessness, and a sense of personal “incompetence” that may be tied to a loss of or threat to one’s own goals or values.”] pandemic has already descended upon us. While the pandemic has fostered more conversations about mental distress and illness, no robust system has emerged to take care of those who take care of others.[2. It is not only health care workers who would benefit from care from people and systems.] (How could we expect a robust system to emerge when the system—if there was one—was fragile prior to this pandemic?) This distress manifests in dreams and dissociation, prickliness and physical pain, withdrawal and wretchedness.

I never formulated my specific work as “public health psychiatry”, though, in the months before the pandemic, this idea crystalized in my mind. Most of my career has focused on the “deep end” of the system: homelessness, crisis, jails, and poverty. While people can and do get better, the challenges are great when one is reacting to, rather than navigating through, these barriers and systems.

So much of what I do is tertiary prevention (“managing disease post diagnosis to slow or stop disease progression“). Fewer people would need “deep end” services if there were more agile and reliable primary and secondary prevention systems. How much healthier would people be if they were never sexually assaulted as children? if parents were able to feed themselves and their children with confidence? if everyone had a stable and safe place to live?

For our health care workforce now, it is too late to prevent demoralization and exhaustion. It seems that the best that we can do is prevent more harm from happening. Tertiary prevention is still prevention, though this is hard to reconcile with the realities of our daily work: Will tertiary prevention buoy us enough so that we can give good enough care to our patients?

Categories
COVID-19 Education Reflection Seattle

On Pushing Vaccines.

This summer is like last summer: We (a homelessness and housing agency) have had very few Covid cases in the past month or so. If this year is like last year, our reprieve will end in mid-autumn.

With this lull, I received recommendations to send out information about the current state of the pandemic as it relates to our agency. I hemmed and hawed before writing the crappy first draft: Everyone is tired and no one wants to read another e-mail. In this draft I waffled about commentary about vaccinations.

While vaccination rates in the Seattle-King County area are around 70% (and thus higher than other parts of the country), this doesn’t mean that everyone has been eager to receive a vaccine. There are people who have made a firm decision to forever decline it. There are also people who remain unsure.

I have felt disappointed and weary upon hearing the disdain of leaders and experts towards people who have not gotten vaccinated. I understand their frustration: No one wants to see people get sick and die. There are many ways to die and dying from Covid-19 is an undesirable way to leave this world.

That being said, scolding or berating people to make a specific choice is rarely (if ever) effective. If someone tells you that you are selfish because you won’t eat vegetables, that probably won’t increase the chances that you will eat vegetables. You might instead avoid this specific someone: Who wants to hear that they are a selfish person? (You can replace eating vegetables with any other behavior, identity, or choice: You are a selfish person because you choose to believe in liberal political ideas. You are a selfish person because you think abortion is wrong. You are a selfish person because you want to defund the police. You are a selfish person because you believe that Jesus was crucified for your sins. Calling someone selfish rarely promotes inquiry or conversation.)

People have shared with me a wide variety of reasons as to why they don’t want to get vaccinated. Some of those same people end up getting vaccinated… maybe because of our conversation, maybe not. I suspect that most didn’t even share all of their reasons with me because they might have felt embarrassment if they did.

If someone is willing to talk with you about a choice they want to make, that also means that they are talking with themselves about that very choice. Any conversation you have with them may carry on in your absence.

I don’t know if this is actually an adage in psychiatry, though I recall several people sharing this while I was in training: As long as someone is alive, there is still hope. Things can still change. People want to make their own choices, though; no one likes coercion. People aren’t stupid, either: They often know when someone is using force to try to change their minds or behaviors. (This use of force doesn’t have to be dramatic either: It can be a simple statement like, “I need loyalty.“)

As long as someone is still alive, there is still hope, and we can use that hope to keep the conversation going. People will share their worries with you if they are willing to give you the chance to change their minds. They will only give you that chance if they have some trust in you. They will have some trust in you if you have genuine interest in their worries and beliefs. People want to be understood. People want dignity.

You may fear that there isn’t enough time: What if they get infected with Covid-19 tomorrow and die next week? Maybe if we put more pressure on people, they will move faster.

Alternatively, if we put undue pressure on people, they may choose to never speak to us again. Any time that we did have is now completely gone. You can play the long game or you can prematurely end the game.

To be clear, I’m not saying any of this is easy or that a select few of us have magical abilities and endless patience to help people change their minds. I do, however, have experience working with people who were not making choices that I wish they would make: People who were living outside and refused to move into housing due to beliefs that were not rooted in reality. People who were using drugs and alcohol for many years. People who declined to take medication even though literally everyone else witnessed their improved health, wellbeing, and function when they did so.

Sighing and making exasperated comments at people who are living outside rarely makes them move into housing faster. Yelling at people who are using drugs and alcohol almost never makes them stop using. Forcing people to take medications does not make medications suddenly more appealing to people who usually refuse them.

Am I fully vaccinated? Yes. Do I wish more people would accept the Covid vaccines? Yes. Do I think threats or domination, even in slight forms, will succeed? No. At this point, efficiency no longer seems effective.