Categories
Homelessness Policy Public health psychiatry Seattle

Housing as the Most Effective Treatment.

(I know it’s been a minute since my last post. The announcement from HHS about “HHS, ONDCP, and HUD Launch First-Ever ‘Treatment First’ Toolkit to Combat Homelessness and Addiction” reminded me that I submitted the op-ed below at the end of June. The newspaper chose not to publish it, so I’m sharing it here. I’ll review the toolkit above next, though I have a feeling that I may reiterate what I’ve already written below.)

The Trump administration believes that mental illnesses and substance use disorders are the root causes of homelessness. Thus, HHS Secretary Kennedy recently announced funding for the Safety Through Recovery, Engagement, and Evidence-based Treatment and Support (STREETS) program. Because of the “unprecedented burden and impact of addiction and mental illness among the homeless population”, he asserted that this funding “aligns with President Trump’s Executive Order on Ending Crime and Disorder on America’s Streets”.

STREETS may help people with mental illnesses and substance use disorders, but it will not end homelessness. People need safe places to call home to recover.

The vast majority of people with mental illnesses and substance use disorders are not homeless. In Washington State, over 2.2 million adults have had any mental illness and over 1.4 million people over the age of 12 have had a substance use disorder in the past year. Compare these numbers with the 163,000 Washingtonians who are homeless. If we (incorrectly) assume that every person became homeless because of a mental illness or substance use disorder, that means over three million Washingtonians will lose their housing. This is wrong. Someone in a Mercer Island mansion drinks bottles of wine between meetings, just as someone in an Auburn apartment takes medication for schizophrenia before going to work. 

I work as a psychiatrist in Seattle with people who are currently and formerly homeless. Psychiatric conditions that are common in the general population, like anxiety and depression, are also common among those who are homeless. For many of them, housing is the most effective treatment. Having reliable access to one’s own bathroom and bed reduces stress. A lock on the door assures safety and security. 

Practically everyone who is homeless now has had a place to call their own in the past. Because of rising rents, reduced incomes, and the onset of health problems, nearly half of people becoming homeless for the first time are over the age of 50. With older age often comes increased physical and cognitive vulnerability. Anxiety and depression often follow. The loss of health and housing can tip people into major mental illnesses and substance misuse. 

In a minority of people, severe mental illnesses and substance use disorders are the primary drivers of their homelessness.  Because of their symptoms, they sometimes are unwilling or unable to work with traditional health care systems. Finding these individuals is often the hardest part of my job. I cannot build relationships and then offer treatment if I cannot find my patients. When someone has a stable and safe place to live, it is far more likely we will connect. Only then can people participate in care.

For those who are unable or unwilling to engage in outpatient treatment, civil commitment is the last option. Laws for involuntary hospitalization already exist. Every day, someone is hospitalized against his will. In many instances, this is lifesaving. However, recovery quickly unravels if people have nowhere to go when they are discharged from the hospital. It is hard to attend appointments, take medication consistently, and build a life you want to live when you don’t know where you will sleep.

To be fair, STREETS funding will help the health and wellbeing of some people, including individuals who are homeless. Prevention and early intervention work. Some people at risk of becoming homeless because of mental illnesses and substance use disorders will remain housed. However, psychotherapy and medications are often no match for the stress and chaos that comes with homelessness. Housing is health care.

RFK Jr. has shared his own history with drug use and depression. As far as we know, he never experienced homelessness. Having a stable place to call home was foundational to his recovery. He knew where he could go after attending 12-step meetings; he had a safe place indoors to read books by Carl Jung. Housing alone does not treat mental illnesses and substance use disorders. But treatment alone also doesn’t solve homelessness. People need both. 

Categories
Education Reflection

Seen Around the Internet.

Three recent items for your consideration:

Psychiatry in the Public Square. As if in response to my post asking for post suggestions, this essay appeared. The author, Adrian Preda, argues:

Psychiatry and mental illness remain inadequately represented in public discourse, and when they do appear, the representations are often partial, distorted, and repetitive.

He offers “four principles of engagement”:

Visibility. “Psychiatry needs to be present where the public already is—not only in newspapers and medical journals, but on podcasts, YouTube, social media, and the other platforms that increasingly function as people’s primary sources of health information.”

Correction. “When mental illness or psychiatric treatment is portrayed inaccurately—as they regularly are—psychiatry should react quickly, clearly, and constructively.”

Education. “Beyond correcting myths, psychiatry should proactively use media to provide practical, accessible information.”

Collaboration. “Psychiatry cannot improve its public presence by speaking alone.”

I am trying! (It is also true that I am ambivalent.)

Thanks to those of you who responded to my request for suggestions. I may not have the largest audience, but it seems that I have a devoted one. Thanks the gifts of your ongoing attention.

Drowning Doesn’t Look Like Drowning. Please be generous and share this. Here’s a 1:20 video that covers the same information, but it induces way more anxiety than the article.

“I Feel Good”: The Many Flaws of the Wellness Movement. Arthur Caplan is a giant within bioethics. This article is a book review, but he throws in plenty of grouchy editorial comments. His opinions about the wellness industry are clear.

He rightly points out:

… proponents of wellness have one thing in common—it is up to you to do something. Social determinants and economic conditions that drive health just don’t get much attention.

And even when it is up to you to do something, the wellness industry tends to gloss over the unsexy basics: Sleep enough. Eat just enough. Get outside and exercise every day. Cultivate and maintain relationships. These activities don’t sound as alluring as putting a stone egg in your vagina. (Look who’s grouchy now?)

Caplan closes his essay with sound and exhausting counsel: “Being well means taking steps to change your behavior and demanding the EPA go back to its mission of protecting you from pollution and environmental hazards.”

Categories
Uncategorized

Wanted: Your Suggestions.

Dear reader, what topics would you like me to write about?

Some of you have given me the gift of your attention for months, if not years. (Thank you!) I’m never sure what draws people back here to read my writing.

Now that I am clearly a “middle career” psychiatrist, I feel a duty to share what I know. This moment in time feels unstable. My professional niche seems atypical. It feels important to contribute what (little) I know in case it can help someone, somewhere. (Sharing what I know here also helps me improve my writing skills.)

So, I welcome your feedback and suggestions. What would you like to read here? What questions do you have? How can I be useful within this context?

Comments are open, so feel free to share your ideas there. You can also send me an e-mail at maria at mariayang dot org. If you’re reading this through the e-mail newsletter, you can reply to the e-mail.

Thank you!

Categories
Homelessness Observations Public health psychiatry Systems

Psychiatry in Context.

A few reactions on topics related to psychiatry from the past week:

An example of a transitional object in baseball. The catcher for the Seattle Mariners, Cal Raleigh, did not play a few games due to injury concerns. Early in the game against the Atlanta Braves, the camera operator lingered on him in the dugout:

Cal Raleigh leaning against the dugout railing while holding a baseball (transitional object) in his right hand. A water bottle is directly in front of his face on the railing.

Notice that he’s not dressed to play. An unmarked bottle keeps him company. In his right hand is a baseball.

The Wikipedia page about transitional objects is pretty good (though psychobabbly). The best explanatory example of transitional objects is Linus and his security blanket:

Transitional objects give us comfort and a sense of security. Maybe the baseball gave Cal comfort and security during his mandatory time off. (Some players can hold six or seven baseballs in one hand. That’s probably more about showing off!)

The MAHA Action Plan to Curb Psychiatric Overprescribing. Per the HHS press release:

HHS Secretary Robert F. Kennedy, Jr. laid out a new action plan to promote appropriate psychiatric prescribing and drive deprescribing when clinically indicated.

Does “inappropriate” psychiatric prescribing happen? Yes. Does deprescribing, whether clinically indicated or not, already happen? Yes.

Back in 2015, while mulling over the value of psychiatrists, I commented:

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications.

Many psychiatrists practice “deprescribing”. In 2019 I wrote about the ongoing difficulties in treating psychosis. There I commented on my own deprescribing experiences:

One of my early jobs was working in a geriatric adult home. My work there taught me that people with psychotic disorders can and do get better. The burdens of antipsychotic medications—paying for medications, the actual act of swallowing the pills every day, the side effects, some mild, some intense—add up. I was fortunate to work with some people to successfully reduce the doses of their antipsychotic medications and, in some cases, stop them completely! (There [was] also at least one instance when tapering medications was absolutely the wrong thing to do; that person ended up in the hospital. I felt terrible.)

Psychiatry is an easy target. Psychiatric medications, especially antidepressants, are common prescriptions. Many factors contribute to this: Health care appointments are short. (There’s not enough time for deep conversations.) It’s hard to access non-medication treatments. (Most rural areas do not have experts in evidence-based therapies.) Emotion literacy is not where we all want it to be.

For several decades psychiatry has focused on biological causes of psychological symptoms. The natural corollary is medications fix biological problems. As I noted in 2019, “Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.”

To be clear, I am not anti-medication. Psychiatric medications can not only save lives, but also improve quality of life. However, medications are not the only tool psychiatrists have to help people. Most of us do prescribe appropriately. (Some people are vexed when we decline to write prescriptions.) Many of us do deprescribe when clinically indicated. (Some people express anxiety when they want to stay on their medications.)

Ongoing hypocrisy related to “ending crime and disorder on America’s streets”. The primary community psychiatry journal published this (free) article: The Executive Order on “Crime and Disorder”: An Affront to Policy, Law, and Ethics.

I agree with the authors. I previously shared my reactions to the executive order here.

It’s fresh that the federal administration cannot recognize the crime and disorder they bring to America’s streets:

… among many other federal actions that reduce stability and increase anxiety. Choose your issue.

Categories
Reflection

Other Lessons from the Artemis II Mission.

Now that the astronauts from the Artemis II mission are safely back on Earth, here are more reactions about what we heard and witnessed:

It’s okay to ask questions. The crew aboard Integrity asked mission control many questions. They ranged from confirmation about what they thought they heard, to where they should store items, to repeating of instructions. They did not hesitate to seek clarity whenever possible. They avoided making assumptions.

Mission control often provided guidance in the form of positive reinforcement. It was a pleasure to watch how to shape conversations with ease in short amounts of time. For example, during the lunar flyby, the Science team said things like, “Thank you! The descriptions of the colors you are seeing are really helpful. We look forward to hearing more about colors.” There’s so much packed into those three short sentences. By frequently saying thank you and offering encouragement, the team on Earth was helping to promote good morale among the astronauts. The Science team was also giving positive reinforcement to the astronauts for something they were already doing (describing lunar colors). And the team was giving clear instructions that they wanted more information specifically about colors. One of the best ways we can improve communication is to point out what people are already doing well when they convey information.

The male astronauts can and should be models of masculinity. It was refreshing to see and hear how the male astronauts were working with different team members, in contrast to some males in high positions within the federal government. The astronauts frequently spoke of love, gratitude, and unity. They did not bloviate. They did not make threats; they did not belittle others. All of this might sound soft and squishy, and maybe it is, but these same people were living in close quarters in space, staying calm and communicating clearly when things weren’t going as expected, and enduring stressors that most of us cannot fathom. To execute this mission they were required to practice physical, mental, and emotional discipline for many years.When they asked to name a lunar crater after Commander Wiseman’s deceased wife, they exhibited a humanity and tenderness that we rarely see in our leaders.

The female astronaut can and should be a model of femininity. She was the one who addressed issues with the toilet! Her hair was always aloft because of microgravity, but it didn’t matter. She and her fellow astronauts seemed to treat each other as equals. She didn’t need to wear jewelry, layers of makeup, or fancy clothes to capture people’s attention and respect. Like her male colleagues, she seemed comfortable with who she was, and her self-confidence made her and her work shine.

These were middle-aged people! While none of the astronauts were old, they also were not young. Brains and minds tempered by time, training, and experience are probably better suited for such a profound mission. Those of us who are similar in age to the astronauts now must confront the fact these astronauts underwent a rigorous experience that we, theoretically, could also undertake. So what’s stopping us?

I wish the astronauts had more time to recover before appearing before the audience in Houston. Less than 24 hours after they took a journey around the moon, travelled nearly 25,000 miles per hour through space, and then landed in the Pacific Ocean, they were expected to say something coherent in front of an audience? I hope someone explicitly told them that this public appearance wasn’t for them. It was for their team and the rest of us; everyone wanted to see them alive and well. But it is sure unfair to ask people who just underwent an intense physical and psychological experience to show up and say something as if nothing major had happened to them or us.

May the astronauts find ways to integrate this experience into their lives and have peace. Commander Wiseman correctly noted that only the four of them will understand the experience they just had. This, of course, gives them a deep interpersonal bond that only they can appreciate. However, this can also lead them to feel grief and isolation. They prepared for years for that experience and now it’s over. Most of the people in their lives will never comprehend what they went through. Words are also often insufficient. Throughout the mission, though most often during the lunar flyby, the astronauts said things like, “This is indescribable” and “There are no words”. When we rely on language to communicate external and internal experiences with each other, what do we do when we lack the vocabulary to describe what happened?

The astronauts are people with their own flaws and foibles. Despite that, they have been sources of inspiration for so many. The purpose of the Artemis II mission was to learn more about the moon. This mission also helped us learn more about ourselves and who we can be.