Categories
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.

Categories
Consult-Liaison Education Medicine Nonfiction Systems

More Annotations on the Britney Spears Transcript.

I have not paid close attention to news about Ms. Britney Spears’s conservatorship over the years, though was interested to learn what she recently had to say about it. I felt both sad and disturbed after I read her remarks. (Here’s an audio recording, too.)

To be clear, I don’t know anything about her, her diagnoses, or the specific details of medical care she has received. Despite spending most of my career working with people with conditions like schizophrenia, bipolar disorder, cognitive impairment, substance use disorders, and often major medical conditions, I have referred very few people for guardianship… and none of them presented like Ms. Spears. I have never provided care to public figures or similar VIPs.

Following are the reactions and questions I had upon reading the annotated transcript of her testimony, for your consideration:

They all said I wasn’t participating in rehearsals and I never agreed to take my medication, which, my medication is only taken in the mornings, never at rehearsal.

I don’t know what medications she takes. If she is referring to any psychiatric medication here, this hopefully suggests that her medications cause only minimal, if any, sedation. Many medications usually prescribed for conditions like schizophrenia and bipolar disorder can make people feel tired, sleepy, or sluggish, particularly when people first start taking them.

I was told by my at-the-time therapist — Dr. Benson, who died — that my manager called him in that moment and told him that I wasn’t cooperating or following the guidelines in rehearsals.

I don’t know the terms of her conservatorship, though it is uncommon for managers to be able to call a patient’s therapist or doctor. Can you imagine if your boss were able to call your doctor to report that you weren’t “cooperating or following guidelines”?

Maybe there are releases on information on file for her manager and doctor to talk to each other, though most people don’t want to mix their personal and professional lives like this. That being said, I have had friends or parents of people under my care call me to share information with me, though they understood that I would say nothing in response. I’ve never had a teacher or boss call me, though.

And he also said I wasn’t taking my medication, which is so dumb because I’ve had the same lady every morning for the past eight years give me my same medication, and I’m nowhere near these stupid people.

So many questions here! Who is this “same lady”? Is this a health care professional, like a nurse? For “every morning”? For the “past eight years”? Does she actually need someone to give her medications every morning? Is she unable to do this herself? (This seems unlikely if she is able to “[rehearse] four days a week”, “[direct] most of the show”, and “[do] most of the choreography”.) Or is the purpose of this “lady” to enforce and report compliance? The usual goal is to help promote people’s autonomy and independence, since no one wants to undergo monitoring like this… especially for eight years!

Presumably this “lady” is also using a medication administration record for Ms. Spears so there is written proof of what she is or is not taking. This might be one way the therapist would know that she “wasn’t taking [her] medication”.

Three days later, after I said no to Vegas, my therapist sat me down in a room and said that he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false.

An accurate and truthful medication adherence record would provide proof to both Ms. Spears and her therapist about whether she was taking her medication. This is a document that attorneys, judges, and other people could review.

He immediately, the next day, put me on lithium, out of nowhere. He took me off my normal meds I’ve been on for five years…

If I am reading this right, this means she was under medication administration monitoring for eight years and had been taking the same medications for at least five years (though she said eight years earlier). This suggests a stable medication regimen that she was able to tolerate.

… lithium is a very, very strong and completely different medication compared to what I was used to.

Lithium started at aggressive doses can indeed be “very, very strong”. “Strong” doses of lithium are most often used for people experiencing “mania”, which is a component of bipolar disorder. “Mania” doesn’t mean someone who is “happy” or simply “euphoric”. Mania, in its more extreme forms, looks like increasing amounts of energy in the context of decreased sleep (sometimes for only a few hours, if at all) for many nights, sometimes lasting weeks. People often demonstrate significant changes in behavior during this period of time, such as spending large sums of money they don’t have (e.g., via credit cards) and doing impulsive things that are uncharacteristic of them (e.g., starting businesses with no foundation, having sex with people they don’t know, using drugs or alcohol). Sometimes these combination of behaviors are lethal: People will jump from heights, having full confidence that they can fly.

The thing is, lithium usually doesn’t work that fast. Usually people who are experiencing mania receive lithium to prevent the next episode. They also take something else (ideally for a short period of time) to treat the current episode.

You can go mentally impaired if you take too much, if you stay on it longer than five months.

I don’t know what she means here. Some people take lithium for years (decades!) and they do not “go mentally impaired”. In fact, lithium can be literally lifesaving and keep people well and out of the hospital.

Lithium at high doses, if not properly monitored, can cause sudden changes in mental status and emergency medical problems.

But he put me on that, and I felt drunk.

Yes, this can happen, particularly if the starting dose is high.

I told them I was scared and my doctor had me on — six different nurses with this new medication come to my home, stay with me to monitor me on this new medication, which I never wanted to be on to begin with. There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.

Six different nurses? Who were staying with her? When people (recall that my experience is limited to non-VIPs, which makes up most of us) are in an intensive care unit (ICU) for a major medical problem, there’s ideally one nurse working with only two patients. Six nurses to one patient is a lot. Maybe she meant she worked with six different nurses, but there was only one nurse in her home at any given time?

People who start taking lithium at conservative doses don’t need this level of monitoring. People who start taking lithium are often still working, taking care of their kids, going to school, etc. When people start taking lithium in a psychiatric hospital, this intensity of monitoring doesn’t happen.

Lithium can be sedating, particularly at high doses, which might be why these nurses prohibited her from driving. But for a month? Does this mean that the dose of lithium was changing/increasing over the course of the month? Or they were overly cautious?

He acted like he didn’t know, but I was told I had to be tested over the Christmas holidays before they sent me away when my kids went home to Louisiana.

It seems that she means psychological testing here, though perhaps this also included getting blood drawn to check the amount of lithium in her blood? This latter bit is called a “lithium level”. As noted above, high levels of lithium can be toxic, so people who take lithium get “lithium levels” drawn on a routine basis to ensure that the levels are not near/at toxic levels. Lithium can also affect the function of kidneys and the thyroid gland, so health care professionals often check these labs, too. If the blood draw doesn’t show any lithium, then that means the person hasn’t been taking it.

Over the two-week holiday, a lady came into my home for four hours a day, sat me down and did a psych test on me. It took forever. But I was told I had to. Then, after I got a phone call from my dad saying, after I did the psych test with this lady, basically saying I’d failed the test or whatever.

I don’t know what this is, either. Did the “psych test” last four hours? (Was it a Structured Clinical Interview for DSM-5? I am skeptical: Why would someone start a medication and then do a “psych test”?)

If you don’t build rapport with people, they will provide incomplete or inaccurate information to you. The onus is on the interviewer to build rapport with the patient. I don’t know what it means to “fail” a “psych test”.

“I’m sorry, Britney, you have to listen to your doctors. They’re planning to send you to a small home in Beverly Hills to do a small rehab program that we’re going to make up for you. You’re going to pay $60,000 a month for this.”

I don’t know what “rehab program” means here. “Rehab” often refers to treatment for substance use disorders, though there are no indications to use lithium for substance use disorders. Psychiatric rehabilitation is also a thing, though this usually refers to providing education and support to people regarding social skills, gaining independence, and other strategies to prevent return to psychiatric hospitals and other intensive models of care. The goal is to keep people in the community and away from institutions.

I worked seven days a week, no days off, which in California the only similar thing to this is called sex trafficking, making anyone work, work against their will, taking all their possessions away — credit card, cash, phone, passport card — and placing them in a home where they work with the people who live with them. They all lived in the house with me — the nurses, the 24-7 security. There was one chef that came there and cooked for me daily, during the weekdays. They watched me change every day — naked — morning, noon, and night. My body — I had no privacy door for my room, I gave eight gals of blood a week.

This sounds like an extreme and unethical version of a “therapeutic community”. (The evidence supporting the application of therapeutic communities isn’t great, though some people who have gone through such programs swear by it.) This sounds more like an upscale jail, which, to be clear, is still a jail.

Humans hold less than two gallons of blood, so I don’t know what she means here. Did she undergo a lot of blood draws? To check her lithium level? To monitor whether she was using any drugs or alcohol? (Checking urine is a less invasive way of doing this.)

And ma’am, I will tell you, sitting in a chair 10 hours a day, seven days a week, it ain’t fun. And especially when you can’t walk out the front door.

If she spent most of her time “sitting in a chair”, then maybe this wasn’t a therapeutic community (and more like jail). People usually have to do chores and attend meetings in therapeutic communities. People in (non-VIP) psychiatric hospitals also don’t spend 10 hours sitting in a chair for seven days a week.

I don’t even drink alcohol — I should drink alcohol considering what they put my heart through. Also the Bridges facility they sent me to…

Today I learned about Bridges to Recovery, “residential mental health treatment in a private, luxury environment”. Is this where she went? Bridges to Recovery is part of Constellation Behavioral Health, which is owned by New MainStream Capital.

New MainStream Capital is a “private investment firm specializing in strategic equity investments in leading middle market companies with an emphasis on sustainable growth trends in both the business services and healthcare services industries.” This tells me that they are more interested in getting as much return on investment for their shareholders than providing quality care to people at Bridges to Recovery.

They have me going to therapy twice a week and a psychiatrist. I’ve never in the past had — wait, they have me going, yeah, twice a week, and Dr. [unclear] — so that’s three times a week. I’ve never in the past had to see a therapist more than once a week.

Yes, that’s a lot of therapy. People who participate in psychoanalysis go to therapy four to five times a week. However, psychoanalysis under normal circumstances is a voluntary process. (Full disclosure: I am biased against psychoanalysis.) If the psychiatrist is providing medication services only, that’s a lot of psychiatrist visits. Maybe they know a lot more than I do: How much meaningful medication tinkering can a psychiatrist do with meds every week, when the mechanism of action for so many psychiatric medications remains unknown? (Exhibit A: The serotonin hypothesis.)

I have a friend that I used to do AA meetings with. I did AA for two years. I did three meetings a week. I’ve met a bunch of women there. And I’m not able to see my friends that live eight minutes away from me, which I find extremely strange.

It sounds like Ms. Spears found AA helpful because of the support she got from her community. Much of what she reported in the transcript sounds like absence of community, which of course will have negative effects on her mental health and wellbeing.

I wanted to take the ID [IUD] out so I could start trying to have another baby. But this so-called team won’t let me go to the doctor to take it out because they don’t want me to have children, any more children.

Many have already commented on her statement that she is not allowed to remove her IUD and how this relates to reproductive justice. This also makes me wonder if she is taking any medications that might result in birth defects.

I am sorry to say that I have had women under my care who underwent involuntary hysterectomies due to their psychiatric conditions. All of these women were in their 70s and 80s, so none of these were recent events, but these women usually were not told that their uteruses were surgically removed until after the fact. By the time I saw them, they were taking minimal (if any) psychiatric medications and were not demonstrating symptoms that would warrant an irreversible intervention without any discussion about it.

There is so much that we don’t know about Ms. Spears and what has happened. I only hope that, if she has experienced injustice at the hands of individuals or systems, she will be vindicated and systems will change for the better.