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Blogosphere Policy Public health psychiatry Systems

Prevention and Early Intervention in Psychiatry.

Two shops on a street, one a cafe and the other selling vintage goods. The building is made of brick and it's sunny outside.
Photo by Suzy Hazelwood

The inimitable Dr. Ryan McCormick recently wrote a piece that summarized research findings that he, as a primary care physician, can apply in clinical practice. In the section describing outcomes related to antidepressant dose, he notes:

As an aside, it may be shocking to note that psychiatrists prescribe only 21% of the antidepressants in the U.S., with the other 79% of prescriptions usually coming from primary care providers!

(Similarly, primary care providers write about half the prescriptions for benzodiazepines.)

Much of the burden of psychiatric services falls to primary care and emergency medicine. Some data suggest that nearly 60% of US counties do not have a single psychiatrist. While primary care and emergency medicine physicians can and do provide psychiatric services, they can be put into positions where they are addressing psychological issues beyond their scope of expertise. I mean no disrespect in writing that. Just as it is a terrible idea for me, a psychiatrist, to manage complex diabetes, it is unideal for non-psychiatrists to manage complex psychiatric conditions.

Sometimes people end up developing complex psychiatric symptoms and conditions because they are unable to access support, care, and services earlier. As a result, larger numbers of people end up accessing services in urgent or emergent ways (e.g., emergency departments and criminal-legal systems). Local jurisdictions then receive increasing demands to build crisis response systems. For example, Seattle-King County recently announced a future ballot measure to build five mental health crisis centers in the region.

There will always be a role for crisis centers, as life is unpredictable and collisions of fate and bad luck can result in crises. However, if the crisis system has the most open doors and is the most robust part of the system, then this will only increase the number of people who will use that system.

We can pick any point in a theoretical journey through the crisis system, but let’s start with the crisis center. Let’s say that all five centers have been established and that these centers receive the most dedicated funding and attention. Maybe John Doe is able to access the crisis center directly, which is a boon to first responders and emergency departments—it’s one less person they need to provide care for (and they’re often are not the best suited to give support, anyway). Once John Doe is not as overwhelmed, what are the next steps?

If the crisis centers have received the most dedicated funding and resources (staffing, advertising, etc.), that probably means that other resources—like step-down units or outpatient clinics—will not have the same level of support. Thus, it might be weeks or maybe even a few months before John can get into a clinic.

John can do the best that he can to make it until that appointment, but what if something else happens and he need urgent care? His choices might be limited to an emergency department (which, no offense to my ED colleagues, are not therapeutic places to be) or to return to a crisis center. He might call a first responder, but that might entail an encounter with law enforcement (which is often not people’s first preference). Unless other resources are made available—unless there are other pathways he can take—he will continue riding the merry-go-round that is the crisis response system.

This is why it is essential to build and sustain prevention and early intervention system while also building crisis response structures. The tired phrase is “moving upstream”, but that is the most stable way to get people out of the crisis system.

I agree (to a point) with the New York Times’s editorial board: The Solution to America’s Mental Health Crisis Already Exists. This article provides an accurate history of how a vision of community-based care for some of the most psychiatrically ill and vulnerable people in our communities got degraded. Do I think it is the solution? Only when I feel particularly optimistic. Do I think it is a solution that could yield great rewards? Yes, though ideally this would be paired with other non-medical, community-driven prevention and early intervention efforts.

Prevention and early intervention systems don’t need to formally reside with medical or legal structures. In fact, it is better for the whole community if they don’t. (Let’s not kid ourselves: The vast majority of people don’t want to spend time in the health care system, particularly with psychiatrists. The health care system can do amazing things, but it is also rigid, expensive, and requires people to jump through a lot of hoops.)

Nathan Allebach recently created a TikTok video that describes the decline of “third places” (and I am relieved that he recognizes that car-dependent suburban sprawl isn’t the sole cause community erosion). I’m not saying that community erosion is the primary cause of psychiatric symptoms and distress. However, the presence of social bonds and community could not only alleviate symptoms, but could also prevent some psychological problems. What if interpersonal social networks were robust and included both more and different kinds of people and perspectives? What if fewer people felt lonely and “Good Neighbor Day” didn’t have to be a thing? (Full disclosure: I have a professional crush on Dr. Vivek Murthy.)

If it is true that at least some psychiatric conditions are “medicalized” sociological problems, then this is an arena where non-medical (though not necessarily political!) interventions could be invaluable. Fewer people would believe that their only option is to ask Dr. McCormick for antidepressant medication for anxiety and depression. Non-medical, community-based activities might be sufficient. Fewer people would need to go to emergency departments or crisis centers because resources and options in the community would be inviting and easily accessible. Maybe two crisis centers, instead of five, would suffice. And people would spend less time with (and money on) health care professionals and services, and more with people they want to spend time with… people in their chosen communities.

Categories
Policy Public health psychiatry Reading Systems

Is Mental Health Political?

Items neatly arranged on a desk, including a clipboard with a blank white sheet of paper and a magnet board with separate letters spelling "politics".
Photo by Tara Winstead

Here’s another piece in the New York Times’s series on mental health and society: Mental Health is Political. (Forgive the generous quoting and quotation marks that follow.) Dr. Carr says:

In medicine, examples of reification [the process by which the effects of a political arrangement of power and resources start to seem like objective, inevitable facts about the world] are so abundant that sociologists have a special term for it: “medicalization,” or the process by which something gets framed as primarily a medical problem. Medicalization shifts the terms in which we try to figure out what caused a problem, and what can be done to fix it. Often, it puts the focus on the individual as a biological body, at the expense of factoring in systemic and infrastructural conditions.

She goes on to say:

When it comes to mental health, the best treatment for the biological conditions underlying many symptoms might be ensuring that more people can live less stressful lives.

… after clarifying that she is

not arguing that mental illnesses are fake, or somehow nonbiological. Pointing out the medicalization of social and political problems does not mean denying that such problems produce real biological conditions; it means asking serious questions about what is causing those conditions.

The crux of her argument is this (emphasis mine):

This principle is what some health researchers mean by the idea that there are social determinants of health — that effective long-term solutions for many medicalized problems require nonmedical — this is to say, political — means.

I think I understand what she is arguing here: There are systems in our culture that contribute to mental distress and illnesses. I generally agree with this. If entry level jobs consistently paid wages that allowed people to rent apartments in cities where they work, that would reduce psychological pressure. The stress of long commutes, public transportation, and car and gasoline costs would disappear. People would have more time to enjoy healthful activities instead of commuting. If people are spending more on housing than they can afford, this leads to the tension of living paycheck to paycheck. Insecurities related to eviction and homelessness grow. None of this contributes to psychological wellness.

However, I also wonder how she defines “political” throughout this piece. Is all psychological distress really “political” in nature? For people who experience auditory hallucinations and delusions, is their psychological distress “political”? (Recall that there are people with a diagnosis of schizophrenia who are not indigent: They sustain employment, pay their rent on time, and lavish their pets with treats.)

Are all nonmedical interventions for mental illnesses—whether “medicalized” or not—“political” interventions? At various times and places, there has been alignment between the political beliefs of the community and those in political power. Did rates of mental distress and illnesses significantly decline? (I don’t know the answer to this; if you do, let me know.) If alcohol use disorders are mental illnesses, does this mean that Alcoholics Anonymous and other 12-step groups are “political” interventions? If people who have lost loved ones to suicide and convene as a group to express grief and support, is this a “political” act?

Should we still describe our psychological distress as “political” when life is inherently stressful? Is the act of commiserating with other medical professionals for support during the pandemic a political act? Maybe it is; maybe we must turn to each other because we recognize that health authorities apparently cannot and will not provide more support to us. But maybe it’s not; maybe this is a community of care we intentionally cultivated over time.

I found some validation for my reactions in this Gawker piece: Failure to Cope “Under Capitalism”. Clare Coffey describes

an application of “the personal is political” so expanded in scope that, for a certain kind of person, personal problems, anxieties, and dissatisfactions are illegible or illegitimate unless described as political problems.

She further notes that

[the] invocation [of capitalism] immediately establishes a phenomenon in the realm of the political, without any further work required.

… if only political problems are legitimate, only political solutions are admissible. This has the odd effect of filtering all attempts at self-integration through a political lens.

By describing problems (like capitalism) and solutions as political, perhaps this absolves us of the work we can (and sometimes need) to do. How can one person’s action have any meaningful impact on a political problem like capitalism? Aren’t systems, by definition, much larger than individual people? She then points out:

But in fact there is no one to adjudicate between you and capital, no one to say yes, that really is too much, let’s reassign this project. …

There is no political program that will release you from the necessity of doing more than you should have to or feel capable of doing, in politics as in every other part of life.

I appreciate her exhortation:

This is your life. You do not have time to wait for the revolution to begin living it. You will always be able to find someone to give you permission not to live it. But no one is coming along to live it for you.

To be clear, I am not at all suggesting that we can eradicate mental distress and illnesses by simply yanking on those bootstraps. The statement that “mental health is political”—to me, at least—removes any agency we have as individuals. Yes, political interventions and actions can improve population (mental) health. However, some political interventions will have little to no impact on individual psychological health. There are choices we all can make, on our own, that can help improve our own psychological wellbeing. Furthermore, we each can make choices everyday that can improve the psychological health of the people within our six-foot radius. Our actions don’t have to be political statements.

Given the work that I do, I don’t need much persuasion to believe that systems have many direct and indirect adverse effects on people’s health. It also seems unreasonable, though, that politics will always provide solutions for mental distress and illness.

Categories
Consult-Liaison Observations Reading Reflection

Therapy and the Use of Words.

Photo by Pixabay

A flurry of mental health-related articles have piqued my attention recently, many of which are worth writing about. We’ll start with one article from the New York Times’s new series, It’s Not Just You: A Times Opinion project on mental health and society in America today.

Huw Green, a clinical psychologist, writes in We Have Reached Peak ‘Mental Health’:

The contemporary cultural landscape’s recent zeal for mental health as an important good has been accompanied by a faith in therapy as the best way to obtain it. …

Therapy is important as a valuable health intervention for many, rather than a universal prerequisite to a good life. Most people simply cannot afford to have lengthy therapy, or it doesn’t fit with their cultural or religious worldview. Do we really want to suggest that this compromises their mental health or their ability to do things like parent well?

Recently, a man at work asked me if he should “get therapy”. A horrifying event happened in his life about six months ago. Someone who cares about him has been haranguing him to go to therapy. He wondered if he should heed that suggestion.

I have provided therapy. I’ve also received therapy myself, which I found both helpful at the time and since it ended. How did I respond to this man?

“The only person who can answer [if you should get therapy] is you.” (Which I realize is a shrinky thing to say that is also not helpful. I elaborated further, which is what follows.)

I don’t think there was ever a time that I thought that “everyone should go to therapy”. Can it be helpful? Yes. Can it improve your life in multiple dimensions? Yes.

Can it take a lot of time? Yes. Can it cost a lot of money? Yes. (Do you think about things you’d rather avoid? Often. Do you sometimes dread going to therapy? Absolutely.)

Could you do something else just as valuable and healthful with your time? Yes.

The thing about conventional therapy is that it has a heavy reliance on words. You have to be able and willing to use words to describe your internal experiences, whether they be thoughts, emotions, or behaviors. You have to be able and willing to sit in a room with another person for dozens of minutes, week after week, often for months, and sometimes for years while using words. (… though I personally believe that no one should be in therapy for many years: If you’ve been routinely seeing a therapist for five or ten years and your presenting concerns or symptoms have not improved, is therapy actually helping you?)

And you know what? Not everyone likes using words. Or using words is not one of their strengths. It is true that part of the task of therapy is learning how to use words as a skill and for therapeutic purposes. While some people will, in the course of therapy, learn to use words instead of drinking three bottles of wine a night or making superficial cuts on their limbs, some people will find using words difficult, uncomfortable, or artificial.

Therapy is often the most successful when people have clear goals (that they can express in words). It’s hard to say you’ve achieved a goal when you are unable to describe it through the specific medium of language.

Furthermore, much of the task of therapy is learning about yourself: How do you react to events in life? Do your reactions cause problems or difficulties for you? For others? Does your reaction serve other purposes in your life? (e.g., Are you always apologizing because you always believe that you’re doing something wrong, and this is how you absolve yourself?) What would happen if you viewed life events, whether internal or external, differently? What if you believed you could make different choices? What if the stories you tell yourself aren’t accurate or true?

Do you need to receive therapy to learn about yourself in this way? I don’t believe so.

People can achieve psychological wellness (note: wellness, not perfection, which is what the term “mental health” seems to suggest these days) through many non-verbal activities:

  • playing a musical instrument
  • listening to music
  • dancing or other inspired movement
  • walking alone
  • walking with trees, mountains, and skies
  • drawing, whether the process is seen or unseen
  • running
  • sitting, with or without spiritual practices like prayer

… and other things that don’t involve words.

People want to live healthy, meaningful lives. Huw Green is right: Therapy isn’t required for this.

Categories
COVID-19 Medicine Nonfiction

Stairwell as Sanctuary.

Old, concrete stairwell with brightly-lit windows in the background.
Photo by Ryutaro Tsukata. This stairwell looks similar to the one I frequently used for myriad reasons while I was in residency training.

I wrote the following op-ed in late July, though never submitted it for publication: While I share an opinion, I don’t offer any solutions (and none have come to mind since then). Since President Biden has announced that the pandemic is over, now is the time to share this essay.

There is a stairwell or bathroom in every health care setting that has served as a sanctuary for medical professionals. We hold our breath and stifle our sobs while we stride towards the sanctuary; we wish to get there before anyone sees us weep. The tears fall because we learn a vulnerable patient died. A cherished colleague is leaving. A faceless health insurance reviewer has denied treatment. We run out of options to help someone because of choices an institution made. We wish we knew more, could do more.

As health care professionals, we are familiar with disappointment and sadness. Both are a part of our training and professional experience. We, however, are now experiencing enormous, unprecedented loss. Like ripples on a lake, our reactions to this loss will radiate forth and touch everyone in our communities.

The loss of life from the Covid pandemic looms over us. Over one million people in the United States have died from SARS-CoV2; we provided care to them in clinics, homeless shelters, jails, crisis centers, emergency departments, and hospitals. The individuals did not only die from Covid; others died from social consequences of the pandemic. Under- and untreated medical problems took away quality and quantity of life. Drinking, smoking, and injecting in doses too large offered relief from pain that defied description. Suicide seemed like the best choice among miserable options. We said their names and saw their faces, even as ours were covered with masks and goggles. Out of respect for patient privacy, we do not share these stories. In silence, we think of those who have died. This silence grows because we cannot find words to describe the shape, size, and saturation of our growing grief.

Even if we are able to share our sorrow, we have fewer colleagues around to listen. Diminishing clinical guidance, financial resources, and infrastructure support for health care professionals caused nearly 20% of us to either flee or flame out. (We understand why they left. We think about leaving, too.) Some retired early, others left for jobs that require less contact with distress and disease. They took with them their experience and expertise, which helped not only patients, but also us. Still others, recognizing already limited support dwindling further, took advantage of market forces and took jobs that were circumscribed in time and substantial in compensation. Health care delivery largely occurs in teams. When team members turn over frequently, the lack of team trust and cohesion often erodes the quality of care patients receive.

Earlier in the pandemic, we viewed the CDC as a part of our health care teams, as they have what many of us who work in safety net settings don’t have: Authority, public health expertise, and resources, including time to read and think. Over time, the CDC let us down: Instead of providing reliable and proactive leadership, it dithered. The CDC’s inaction forced individual agencies and clinicians to craft guidance. Why was a psychiatrist left to lead a public health response for a homelessness services agency? We wanted concrete guidance to keep people healthy and out of hospitals; we received a meager menu that deferred to the whims of politics and skeptics. We wanted tests and data to decrease disease spread and deaths; the CDC delayed sending out both laboratory and rapid tests. Recall that wealthy individuals and companies remained at home and procured tests with ease. Meanwhile, people labeled essential workers were treated as inessential: They could not access tests to protect themselves or their families. The CDC betrayed those of us who provide health care; we thus betrayed those who entrusted us with their health.

Health care workers must leave the stairwell or bathroom when our crying stops. Our tears may end, but the needs of patients do not. Physicians experiencing distress may be more prone to making medical errors. Fewer health care workers and disruptions of teams increases the work burden on those who remain, which increases their exhaustion and heartbreak. Without reliable guidance and leadership from a health authority like the CDC, we are unable to deliver unified, coherent health care. This will adversely impact not only the experiences of people who are ill, but will also result in population outcomes no one wants: More disease, more suffering, and more death. It may be too late to reverse this vicious cycle. We wish that we knew more, could do more.

Categories
COVID-19 Nonfiction Public health psychiatry

16 People.

Content warning: This post discusses death and suicide.

Photo by George Becker

Early in my training, someone older and wiser than me made a comment in passing:

There are two types of psychiatrists: Those who have had patients die by suicide, and those who have not.

I assume (perhaps incorrectly) that all psychiatrists eventually join the group where someone under their care dies by suicide. These deaths change us.

The first time I learned that someone under my care died from suicide was during my intern year. I didn’t know him well; I do not remember his name. I was working in a psychiatric unit in a hospital and had worked with him for only one or two days. He had a diagnosis of a psychotic disorder. My sole memory of him is his flat, unblinking expression while he looked at me. Though his face showed little emotion and he said few words, he radiated discomfort.

Within a week of his discharge from the hospital, he had jumped off of a bridge.

I didn’t know how to react. I don’t remember if we had a conversation about him, if anything else had happened, or what we could have done differently.

I do remember the name of the person who killed himself after he and I had been working with each for nearly a year. He was the first of “my” patients who died by suicide.

He earned a professional degree long ago, but was living in a shelter. Alcohol brought him comfort, though it drowned his career. He argued a lot. This was the primary way he knew how to interact with people. Despite his pugnacious manner, he and I built and maintained a respectful rapport.

The medical examiner ruled that he had died from an overdose, though the official did not deem this a suicide. The toxicology report stated that there was methadone and alcohol in his system. He did not like and never used opiates.

I still think of him a few times a year. I still wish he had talked to me before he ended his life.

In any given year, I learn that one or two people under my care have died. Most of the time, the cause isn’t suicide. People age; people get sick; bad luck strikes.

Between January of 2020 and June 2022, sixteen (16) people under my care died. None of them died from Covid. The youngest was in their late 20s; the oldest was in their mid-60s. A few died from suicide; others died from medical problems (some acute, some not). Many died from overdoses. Maybe they were intentional; maybe they weren’t. I will never know.

I recently spoke with a former colleague about the various losses we have experienced over the pandemic.

“No one wants to hear it,” she said with some bitterness. “People are tired of hearing sad or bad news, so they don’t ask about our work or how we’re doing.”

She’s not wrong. It’s not easy for me to talk about it, either, as talking about it means I have to think about it, and it’s hard to think about things that do not make sense and may never make sense: What happened? What happened to us?

Maybe I just want people to know that actual human beings died, that I knew these people, that all these people meant something to someone, that they meant something to all of us who had the opportunity to know them. I wish I could tell you more about the guy who made a handmade Christmas card for me, even though he had yelled at me the first time we met just six months prior. I wish I could tell you more about the woman who had several weeks of sobriety before she collapsed on the sidewalk, her heart pulseless. I wish I could tell you more about the man who always called me “Ms. Dr. Maria” and offered me home-cooked food whenever I visited him at his apartment.

That’s only three people. There are 13 others.

If you’ve lost someone during the pandemic, you are far from alone. A poll from 2021 (!) revealed that about 1 in 5 Americans are close with someone who has died of COVID-19. (Recall that over one million people in the US have died from Covid.) Suicide remains a leading cause of death in the US, with certain groups at higher risk than others. (Also remember that we all can help prevent suicides; it doesn’t have to be the only option.)

It’s okay to feel sad, angry, or disappointed; you feel how you feel. Things will change, as they always do, though they may not change as fast as we want them to. It’s also scary to express vulnerability. Voluntarily shedding the crusty carapace to reveal the soft tissue within, however, may be the best (or only) path forward.