Funding Policy Public health psychiatry Seattle Systems

Crisis Care Centers Aren’t Enough.

The Tacoma News Tribune graciously agreed to publish an opinion piece an esteemed fellow psychiatrist and I wrote. I invite you to read the 500-word essay, Crisis care centers are important. But WA needs more to fill behavioral health gaps, directly through the newspaper (and show a local newspaper some appreciation through page views!). The piece has particular relevance to residents in King County in Washington State.

If you have more time and would like to read the original version, you can find it below. Thanks for your interest.

King County voters will decide whether to fund a network of crisis care centers in April. There are many reasons to support this: We all know people who have experienced behavioral health crises, including kids in school; colleagues at work; family members; and people we encounter in the community.

Because King County currently has only one crisis center, additional centers will help. However, the entire behavioral health system in Washington is in crisis. A narrow focus on these centers only may lead to even more people tumbling into crisis.

King County has explained that these five crisis centers will “provide a safe place… specifically designed, equipped and staffed for behavioral health urgent care. These Centers will provide immediate mental health and substance use treatment and promote long-term recovery.”

If crisis centers have the most resources, they will be the most robust and responsive element of the system. Outpatient clinics providing earlier intervention and prevention services are often understaffed and have waitlists. People already enrolled in these clinics may wait weeks to months for follow-up appointments. Those leaving hospitals also compete for clinic appointments. This excessive waiting can precipitate crises. People should not have to be in crisis to access care.

Crisis care centers are designed to accept anyone, with or without insurance. Many behavioral health clinics have insurance restrictions. Some clinics don’t accept public insurances like Medicaid or Medicare. Others do, though have limited funds to provide services for uninsured people or for those ineligible to obtain insurance. Such restrictions will funnel uninsured people to the crisis centers. Yet, where will they go for ongoing care?

Due to limited resources, crisis care centers must screen and triage referrals. If people experiencing symptoms related to mental illness or substance use don’t meet criteria for admission to a crisis center or a hospital, what then? If under-resourced outpatient clinics remain understaffed or close, these individuals will be forced to wait for treatment. Their symptoms may worsen, precipitating preventable crises, which no one wants.

The option for people to stay up to 14 days in a crisis care center can help people connect to ongoing services. However, many agencies are unable to see people and establish care within 14 days, in part due to what King County described as: “The behavioral health workforce is strained under the magnitude of the need, all while being underpaid, overworked, and stretched too thin.”

The levy touts the use of peer counselors in crisis centers. Peers with lived experience are valuable, though should not be the primary providers of care. Peer counselors often have the lowest wages and, in some for-profit models, make up the bulk of personnel, presumably to maximize revenue. Some people in crisis are among the most vulnerable, ill, and complex patients in the region. Both patients and staff across the entire continuum of care deserve sufficient support and resources to get, and stay, out of crisis. If people experiencing mental health crises receive insufficient services, they are more likely to fall back into crisis and return to these centers. If these crisis centers are operated by for-profit organizations, readmissions will increase their revenue. We have already witnessed this pattern in several for-profit psychiatric hospitals where patients experienced harm. Patients and their families deserve better.

King County needs crisis centers, but personnel in other parts of the system also need support. The levy notes that funding for residential treatment facilities will focus on capital and maintenance. Building conditions are important, though the staff who work in these buildings are just as valuable. Many individuals receive ongoing care in residential treatment facilities following acute hospital treatment. Supporting and retaining staff in these residential programs are vital in reducing behavioral health crises.

Outpatient clinics with robust funding for personnel, technology, and other resources, along with appropriate reimbursement of services—things that never happened after the original deinstitutionalization movement of the 1960s—will help people access care. This, along with preventative efforts and early intervention at the first signs of behavioral health challenges, decreases crises.

Ultimately, supporting peoples’ basic needs will reduce the need for crisis centers. Living wages, affordable housing, access to food, universal health care coverage, employment opportunities, education and training, and building social connections, will reduce psychological burdens and promote wellness. 

This levy should be viewed as an initial investment in improving our battered behavioral health care system. More needs to be done to improve the mental health of our friends, family, and neighbors. 

Consult-Liaison Reading

Biased Thoughts.

The only social media platform I have yet to abandon is Twitter. It’s a good example of “variable ratio reinforcement”. Think of a slot machine: People put money into it with hopes of winning a jackpot. A reinforcer increases the likelihood that a specific behavior will happen. Here, the reinforcer is the pay out. The chance of a jackpot makes it more likely that someone will stay and continue to put money into the slot machine. However, the slot machine doesn’t pay out money on a predictable schedule or ratio. Jackpots happen on a variable schedule. This “variable ratio reinforcement” is what keeps people at slot machines (a specific behavior) for hours.

The Twitter algorithm occasionally (on an unpredictable, variable schedule) shows me interesting and useful information. It recently introduced me to a paper called Toward Parsimony in Bias Research: A Proposed Common Framework of Belief-Consistent Information Processing for a Set of Biases. (Though the paper isn’t too jargony, it is wordy… but worth your attention if you like this sort of stuff.) Of course, this paper played right into my biases: I like parsimony (or, more simply put, in a world of Lumpers and Splitters, I am generally on Team Lumper) and I like thinking about biases and how they affect our emotions and behaviors.

The authors argue that bias is embedded in every step we take when we process information. We already have a set of beliefs. Unless we exert deliberate effort, our thinking habits automatically try to confirm what we already believe. This bias manifests in what we pay attention to, how we perceive things, how we evaluate situations, how we reconstruct information, and how we look for new information.

The authors also put forth the idea that most of our biases are forms of confirmation bias. (The list of biases is biased towards Splitters; see this enormous list of cognitive biases on Wikipedia.) As Lumpers, the authors distill common biases down to two:

  • “My experience is a reasonable reference.”
  • “I make correct assessments.”

As a result, they argue that we can significantly reduce our biases “if people were led to deliberately consider the notion and search for information suggesting that their own experience might not be an adequate reference for the respective judgments about others” (see comment above about article wordiness) and “if people deliberately considered the notion that they do not make correct assessments”.

My mind then ties these biases into the primary framework of cognitive behavioral therapy (CBT). CBT is a type of psychotherapy that focuses on identifying and changing thoughts to then alter emotions and behaviors. The three “categories” of “thought targets” include:

  • core beliefs (things we believe about ourselves, other people, and the world that come from our past experiences)
  • dysfunctional assumptions (we tend to believe “negative” things, rather than “positive” things)
  • automatic negative thoughts (these are “habits of thought” that we are often unaware of; much of CBT focuses on recognizing and identifying these thoughts)

(This is a common complaint about CBT: “So you’re telling me that my problem is that I think ‘wrong’ thoughts. Thanks a lot.”)

If it is true that biases can be reduced to only two, then can we assume that these two beliefs—that we ourselves are reasonable reference points and that we make correct assessments—should be common “thought targets” in CBT? Instead of chasing down every single “automatic negative thought”, could we instead focus on these two common beliefs? (I see value in reframing it this way. Labeling something as an “automatic negative thought” can preclude the value that the thought has in our daily lives. For example, I might have the automative “negative” thought, “I am not entirely safe when I go outside.” However, this automatic thought—which may have led me to take self-defense classes and always monitor my surroundings—may have contributed to me staying out of harm’s way. Astute readers will note that my example included the word “entirely”. It is up for debate about whether the inclusion of that word makes it an adaptive, nuanced thought or a true “negative” automatic thought.)

Focusing on these two beliefs seems to tread into Buddhist psychological thought, too. From a lens of impermanence, are thoughts even real? Can they be sustained? Our ideas—our thoughts—can be reasonable in one moment, and completely unreasonable in the next. Same with our assessments: New data and new context can make our assessments wrong in a moment. And what about non-self? Can we even speak of “my reasonable reference” and “my correct assessments” if, in fact, there is no “self”? And aren’t thoughts yet another concept that keep us trapped in suffering?

So, I think there are three main ideas to take from this post:

  • Twitter has some value, some of the time, and is an excellent demonstration of variable ratio reinforcement.
  • You might be able to significantly reduce your cognitive bias if you adopt two habits of thought: (1) Look for evidence that your own experience is inadequate when assessing other people and situations, and (2) Look for evidence that you do not make correct assessments.
  • An oldie but goodie: You can’t always believe what you think.
Consult-Liaison Nonfiction

Delirium Adventures with ChatGPT.

I still think one of the most valuable skills psychiatrists have is to help distinguish psychiatric illness from “delirium”, which, for the purposes of this post, we can call “acute brain failure”. Other organs can abruptly stop working for a variety of reasons. Hepatitis infections can cause acute liver failure; dehydration can lead to acute kidney failure; we’re all familiar with acute heart failure, too.

Delirium is a symptom of an underlying medical condition. It’s like a fever or a cough: Many conditions can cause fevers or coughs, so you have to seek out the “real” reason. When people develop delirium, their thinking, behavior, and levels of consciousness change abruptly. People can get confused about who or where they are; they might start seeing things or hearing things that aren’t there; sometimes they seem to “space out” for periods of time. These are all vast departures from their usual ways of thinking. (The abruptness here is key; people with dementia may have similar symptoms, but those typically develop over months to years.)

(Fellow psychiatrists and hospital internists recognize that delirium isn’t always that dramatic. Sometimes people are lying quietly in bed, hallucinating and feeling confused, but never behave in a way that would suggest otherwise.)

Because I spent a few years working in medical and surgical units (where the risk of delirium is higher than in the community), it is still my habit to consider delirium when I am meeting with people. Given the disease burdens that people experiencing homelessness and poverty face, this is prudent. (Fellow health care workers might also more likely to believe a psychiatrist when we report that someone might be delirious, rather than psychiatrically ill.)

I wondered if there is any evidence to support that psychiatrists are more likely to detect delirium compared to other health care professionals. Enter ChatGPT.

ChatGPT cited two papers that reported that, yes, psychiatrists are more likely to detect delirium, though shared only the journal and the year, along with a summary of results. I asked for a list of authors for one, thinking that might help narrow down the search. It did not. So then I asked for the title of the two papers.

I could not find either title on Pubmed. This was curious. And concerning.

I then asked ChatGPT to share with me the Pubmed ID (a number assigned to each article) for each paper. Here’s what happened:

ChatGPT said that the first paper, “Detection of Delirium in the Hospital Setting: A Systematic Review and Meta-Analysis of Formal Screening Tools”, was published in the Journal of the American Geriatrics Society in 2018. ChatGPT said that the ID was 26944168. In PubMed, this leads to an article called “Probable high prevalence of limb-girdle muscular dystrophy type 2D in Taiwan”.

The second paper reportedly had the title of “Detection of delirium in older hospitalized patients: a comparison of the 3D-CAM and CAM-S assessments with physicians’ diagnoses”. (CAM stands for Confusion Assessment Method, which is a real, validated tool to help measure delirium.) ChatGPT said that the ID was 29691866. In PubMed, this leads to an article called “Gold lotion from citrus peel extract ameliorates imiquimod-induced psoriasis-like dermatitis in murine”. (I did learn that “gold lotion” is “a natural mixed product made from the peels of six citrus fruits, has recently been identified as possessing anti-oxidative, anti-inflammatory, and immunomodulatory effects.”)

It makes me wonder how ChatGPT generated these articles and their titles, where it created the summaries from, and where it found the PubMed ID numbers.

Indeed, ChatGPT is artificial, but not so intelligent. And it will take me a bit more time to find the answer to my question.

COVID-19 Medicine Nonfiction Public health psychiatry Reading

Things That Made Me Smarter This Week.

Some media recommendations for your consideration:

Three Years Into Covid, We Still Don’t Know How to Talk About It. This article is one of the few that resonated (more) with my experience of the Covid-19 pandemic. Despite my professional training and expertise as a psychiatrist, I still can’t find the “right” words to describe what happened to me, the people around me, and the world. Without adequate words to create a coherent narrative of my experience, I still don’t fully understand what happened. (I hope that I will not give up trying.)

Freedom House Ambulance: The FIRST Responders. Did you know that the first modern ambulance service in the United States was developed in a Black neighborhood in Pittsburgh? The Freedom House Ambulance served as a model for the rest of the world.

This Book Changed My Relationship to Pain (title of the podcast, not my comment). Dr. Zoffness explains the bio-psycho-social nature of pain in an engaging way with plain language. (I am one of the many people she describes in the podcast who developed chronic pain during the pandemic; I have known since its arrival, both as a professional and as a human being, that there is significant a psychological component.) Pain is not all in your head AND the state of our minds affects how we experience pain.

Mathematician Explains Infinity in 5 Levels of Difficulty. I have always found math interesting. What I particularly enjoyed in this video is the skill Dr. Riehl shows in teaching the concept of infinity to different audiences. This is something I aspire to (and have mused about doing something like this for myself for psychiatry, à la the “Feynman Technique“). I also appreciated the similarities between the explanations she provided at level one and level five.

Salve Lucrum: The Existential Threat of Greed in US Health Care. When I read things like this, I see yet another pathway that someone can unwillingly tread upon that will result in homelessness. (Some people think they are immune to homelessness; that’s just not true.) “… unchecked greed concentrates wealth, wealth concentrates political power, and political power blocks constraints on greed”, and “[g]reed harms the cultures of compassion and professionalism that are bedrock to healing care.”

Education Homelessness Policy Public health psychiatry Systems

What I Talked About: Complexities.

Many thanks to those of you who left comments or sent me a note in response to my call for suggestions for a presentation about homelessness and mental illness.

I gave the presentation earlier this week and ended up presenting (a) homelessness data specific to Seattle-King County, (b) general data in in published research about rates of different psychiatric conditions in people experiencing homelessness (there’s actually not a lot of data about this; my understanding is that there is a national study underway right now to assess people experiencing homelessness through structured psychiatric interviews), and (c) the topic of “Involuntarily Removing Mentally Ill People from Streets“. I asked the group—students within various health professions schools—for their thoughts about New York City’s plan.

Many of the students were unfamiliar with involuntary detention for psychiatric reasons, along with the process for how that happens (the laws in Washington State differ from those in most other states in the nation; namely, physicians and other mental health professionals in Washington State cannot detain people directly; we must call a third party, called Designated Crisis Responders, and refer someone for detention). The initial group consensus favored civil liberties; they spoke of loss of dignity, the psychological and physical trauma that can result from involuntary detention, and the importance of autonomy.

When the scenario was adjusted so that the person who was experiencing homelessness and major psychiatric symptoms was someone that the students knew and loved, they quickly changed their arguments to support involuntary detention. When we love someone, we are more comfortable taking away their rights.

Like many complex issues, “right” answers escape us as more facets of the problem are illuminated. Involuntary detention itself is a complicated issue and, because most people are not experiencing homelessness, the majority of people who are detained are people who have an indoor place they call home.

Some research indicates that around 76% of people experiencing homelessness also have a psychiatric disorder, though the association is complex and likely goes in both directions: Some people have a psychiatric condition that contributes to poverty and then homelessness (e.g., losing a job); others become homeless and then develop a psychiatric condition due to the challenges of not knowing where you will sleep at night.

I continue to learn the complexities of working at the intersections of poverty and mental health. I am grateful that more people are interested in this work, too. I hope that things don’t have to get worse before we can offer better help and care to these individuals, who are ultimately our neighbors.