Happy Lunar New Year! May the Year of the Rabbit bring you health, wealth, and peace. I send specific wishes of safety and serenity to those who are afflicted by war. Some cultures believe that there is a rabbit in or on the moon. I hope that those who are living through war know that, when they look at the (rabbit on the) moon, there are other people on the planet who are also looking at the moon and pray for them.
What to Do If a Rat Comes Up Your Toilet. This is actual guidance (in cartoon form!) from the Seattle-King County Public Health Department. Some regions have experienced flooding due to the rivers of rain running through the sky. May you never have to deal with this problem, but if you do, now you know how to proceed.
“If a body sinks and decomposes underwater, scavengers begin feasting — often picking at the soft ligaments and connective tissues of human ankles first, causing the feet to become separated.”
“Changes in sneaker design since 2007 have made shoes more buoyant, as manufacturers began using lighter foam for soles.”
“Since 2007, nearly two dozen human feet in sneakers have washed up along the coasts of the Salish Sea in the U.S. and Canada.”
It is a travesty of justice that law enforcement agencies need “to crowdfund or seek donations from philanthropists” to help identify a deceased person.
The Enduring, Invisible Power of Blond. The incisive and provocative Tressie McMillan Cottom wrote this piece that ostensibly is about the power of blondness; the key quote is this: “When people have outsize emotional reactions to benign inquiries about their self-evident beliefs, it is often an indicator that status is doing invisible work.” Though there are some loud, public pushes to encourage (or cajole or threaten or berate) people to recognize their prejudices and change their behaviors, meaningful shifts actually result from quiet, internal effort. Recognizing and reflecting on “outside emotional reactions” are opportunities, as some say, “to do the work”.
Recommended: Dr. Bill Gardner’s Substack. I first started reading Dr. Gardner’s writing many years ago on the health services blog, The Incidental Economist. He now shares his thoughtful wisdom on I Have Serious News…. Much of his current writing focuses on his cancer diagnosis. He continues to write with clarity, compassion, and insight. If you seek inspiration about clear communication about health, both on individual and population levels, consider subscribing to his Substack.
A belated winter gift for readers: Here are some articles and other media I have found useful and interesting in the past few months, which you may enjoy, too.
Still Processing. This is a podcast from the New York Times. “Wesley Morris and J Wortham are working it out in this show about culture. That means television, film, books, music — but also the culture of work, dating, the internet and how those fit together.” Wesley Morris is a superb writer, too, and has the Pulitzer Prizes—plural! 2012 and 2021!—to prove it.
Lucas Sin. He is a chef who is from Hong Kong and now works in New York. He seems thoughtful, communicates well, and has an understated enthusiasm for his craft.
Mystery Menu. Sohla and Ham are both chefs. Not only do they have expertise in creating dishes from strange ingredients, but they also seem like delightful people.
Building Resilient Organizations. Maurice Mitchell’s analysis of dynamics in progressive organizations is intelligent, incisive, and inspiring. (There are similarities with ideas in John McWhorter‘s writings. I learned about Mr. Mitchell through Chris Hayes.)
Escaping American tribalism: Only personal bravery can end polarisation. William Deresiewicz, like other writers I admire, shares sharp, provocative opinions and insights (“You change your mind when you consent to stop ignoring things you know full well but do not want to think about”). I look forward to reading his most recent book, The End of Solitude: Selected Essays on Culture and Society.
Glass Onion: A Knives Out Mystery. As someone who has read nearly all of Agatha Christie’s novels, it is delightful to see Hercule Poirot reincarnated as Benoit Blanc. It’s a fun movie. (And Edward Norton and Janelle Monáe make such gorgeous eye candy!)
Happy 100th Birthday Charles M. “Sparky” Schulz! Charles Schulz was the creator of the world-renowned Peanuts comic strip. In honor of the centennial of his birth, many cartoonists created a comic strip for this weekend. You can view the tributes here. (Some side comments: As most people read newspapers online now, are there far fewer readers of newspaper comic strips now? I used to read the Sunday funnies throughout my youth; I recognize few of the cartoonists on that tribute page. My favorite strips included Peanuts, Calvin and Hobbes, Non Sequitur, and The Boondocks. For anyone who has even a mild interest in Peanuts, I highly recommend a visit to the Charles M. Schulz Museum in Santa Rosa, California. There are fun exhibits, thousands of comic strips on display, and interesting history about Mr. Schulz.)
Egg Drop from Space. I am one of the millions of subscribers to Mark Rober’s YouTube channel. His most recent video, Egg Drop from Space, is compelling because he shares his major failures in this project. Perhaps he knew that this would make for great storytelling, though he did not have to be this honest and share so many vulnerabilities. (I also completely missed that he was, in essence, trying to design a guided missile.) This isn’t the first time he has brought up failure in his videos, though the extents of his failures make him relatable and his resulting persistence is inspiring. I continue to hope that people will be willing to share their failures, since we’ve all experienced them and will continue to do so. (In that vein, in 2016 I shared a post about My CV of Failures. The formatting is weird because I am unable to use a WordPress footnotes plugin now that I was able to use then.)
“Personal Knowledge Management.” Though I’ve had an interest in technology for much of my life, I would not describe myself as someone who is technologically savvy. There are technologies I routinely use, though I have not uncovered their (or my) full potential. One tool that I have used for several months now is Logseq, which has the accurate description of being a “privacy-first, open-source knowledge base”. (I had dabbled in Obsidian—which I learned about as a loyal Dynalist user for several years—for a while, though personally find Logseq to be more powerful and flexible. As I get older, my appreciation for open-source projects has also grown… though I understand essentially nothing about or in Github.) I’ve not used Notion or Roam Research, but have used Notational Velocity and Tiddlywiki, which are similar “knowledge bases”. If you have used these programs in the past (or even if you haven’t), consider trying Logseq (not a paid endorsement, just someone who is at or near the peak of Mt. Stupid).
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!
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.
This is the third iteration of my blog. I started this one in November 2010. The first iteration of my blog started in November 2000. That means I’ve been writing online for 17 years (???), though I fled the internet for about two years.
In looking back over what I wrote in 2017, these are the posts from this past year that had the most visits:
Disappointment. “My cohort graduated from our psychiatry residency almost ten years ago. The level of frustration and disappointment we’ve all experienced within the past two years is striking.”
My Seattle Times Op-Ed about #MeToo in Medicine. “The senior psychiatry resident at the University of Washington School of Medicine warned me ahead of time. She laughed as she said, ‘He’s weird. You’ll get used to him.'”
Thoughts on the Movie “Get Out”. “If you have seen Get Out, this post ponders the role of psychiatry in the movie. (Full disclosure: I enjoyed and recommend the movie.)”
The most popular posts on my blog, though, aren’t from 2017! These are the posts that received the most visits overall:
DSM-5: Schizophrenia. This post is a brief discussion about how DSM 5 defines schizophrenia. (I wrote about other diagnoses, too, but don’t know why this diagnosis got the most attention. I have a particular interest in people experiencing psychotic disorders; perhaps that shows?)
Personality Disorders to Difficult Interactions (I). “To be clear, though, just because you have a difficult interaction with someone doesn’t mean that that person has a personality disorder. There are plenty of people without personality disorders who behave in unbecoming ways.”
Do People Choose to be Homeless? “I cannot speak for all people who have ever been homeless. However, I have several years of experience working with people who were homeless and refused housing again and again, as well as people who left their housing and returned to the streets.”
I remain grateful to people who choose to take the time to read my writing. Some of you have been reading since the early days of my first blog; for that, I feel humbled. Thank you.
May 2018 bring you all good health, many blessings, and contentment. See you in the new year.
Maria Yang, MD 