Category: Education

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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
Education Nonfiction Systems

Artemis II and “That Psych Stuff”.

The Artemis II mission has captivated me. I find myself checking NASA’s Artemis II Live Mission Coverage on YouTube during in-between moments. So much about this mission astonishes me: The fact that a vehicle is hurtling towards the moon! That there are four people inside! All the math used to plan this trip! That those of us still on Earth get to see and hear the astronauts in almost real-time! (This is the kind of reality TV I can support!) It’s all incredible.

(Let us not forget all the other people who have made this trip possible: The janitors who have kept NASA facilities clean so all staff can think and work in sanitary spaces. The culinary specialists who prepared healthy meals for the astronauts. The accountants who ensured that the mechanics got paid for their work. So many people!)

Within the first day or two, conversations between Houston mission control and the astronauts included the phrase “psychological conferences”. I wondered, “What does this mean?”

When I was in psychiatry residency, a Very Important Person with an Uppity Title at the university hospital was a psychiatrist. When he gave lectures, he routinely shared this perspective:

Psychiatrists have one of the most important jobs in the hospital. Say there are three people in the emergency department. One person is having a heart attack. The second person has a gunshot wound. The third person is trying to grab objects, screaming that they want to kill themselves. Which patient will be the top priority?

(dramatic pause)

The third patient will be the top priority. No one else in the emergency department will be able to receive care safely until that person is de-escalated.

The first time I heard this, I admittedly thought it was self-serving. What a way to puff up psychiatry. However, having witnessed and experienced similar situations, there is truth to what he said.

An emergency department is an enclosed space on Earth with exits to the outdoors. What happens if someone becomes escalated in a capsule in space, thousands of miles from their home planet?

My admiration for NASA has only increased upon finding all the published materials they have about cognition, behaviors, and psychiatric disorders, which are part of their compendium of human system risks. There’s a logic diagram:

NASA master logic diagram that describes risk of adverse cognitive or behavioral conditions and psychiatric disorders; open link to see full text

There are likelihood and consequence ratings to measure “Risk of Adverse Cognitive or Behavioral Changes and Psychiatric Disorders Leading to In-mission Health and Performance and Long-term Health Effects“:

chart that show likelihood and consequence ratings for space missions of varying distances and durations; open link to see full table

The accompanying 222-page report describes a “behavioral health and performance operational psychology” group that works along the spectrum of prevention, early intervention, and mitigation for astronauts. It looks like flight crews receive robust training in psychological skills (e.g., conflict management, stress management, education about psychology). Further support happens during flight, which we are witnessing now. These include—ah ha!—private psychological conferences, social support from Earth, cognitive monitoring, sleep and circadian rhythm support, team cohesion and care, and looking out the windows. (The authors included the comment, “NASA flight psychiatrists and psychologists have reported that during debriefings astronauts state that they did not realize how important ‘that psych stuff’ was until after they were on the [International Space Station].” This is the story of every psychiatrist and psychologist.)

Furthermore, there are reports about the intersecting psychological risks of “extended duration of isolation and confinement, greater distances from Earth, as well as increased exposures to radiation and altered gravity”. These are well outside the scope of my expertise, but there are lessons from space medicine (!) that NASA has already encouraged all of us on Earth to adopt:

graphic from NASA that describes the CONNECT acronym about how to cope with loneliness (community openness, networking, needs, expeditionary mindset, countermeasures, training)

I wish we didn’t have to rely on astronauts to make psychological skills like mindfulness, cognitive restructuring, and maintaining healthy routines sexy, but we’ll take the role models where we can find them!

May the Artemis II voyage be safe and successful. May other people in positions of power and authority learn the patience, cooperation, and discipline from the entire NASA team that made this mission possible.

Categories
Education Observations Public health psychiatry

What is Mental Health? (03)

Let’s take a look at the last figure from the paper What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey. The authors call this the Transdomain Model of Health:

I like this model. (Do note, though, that the map is not the territory.) It reminds us of the interdependencies between and within ourselves. If our community isn’t doing well, that will affect our individual mental health. To intentionally use a trivial example (because there are WAY too many heavy things happening these days), consider a city’s baseball team. A not-so-fictional team called the Tridents has had some embarrassing games; hits are uncommon, fielding errors abound, and pitchers are giving up a lot of runs. Grumpy viewers write corrosive comments about the Tridents in the city’s newspaper. Suckers like me read the comments and feel a disjointed sense of “us”. Maybe some of these grumpy viewers are in foul moods for other reasons and they direct their ire at the Tridents because that’s easier to talk about than their alcohol or gambling problems. They would go to Cell Phone Carrier Stadium to grumble at the Tridents directly, but they are dealing with illnesses that limit their abilities to navigate social spaces. Most of us don’t feel psychologically fine when we are physically unwell.

Contrast this Transdomain Model of Health with this recent Psychiatric News article, Lifestyle Psychiatry Emphasizes Behaviors Supporting Mental Health.

The authors define “lifestyle psychiatry” as seeking

to cultivate well-being and support individuals in preventing and managing psychiatric disorders and optimizing their brain health.

(Editorial comment: I feel some vexation about “lifestyle psychiatry” because I don’t think “lifestyle psychiatry” should be a specialty with its own textbook. Every psychiatrist should practice “lifestyle psychiatry”.) While the authors concede that “patients may have cost or access barriers to traditional care” and conclude the article with a proclamation that lifestyle psychiatry is “a vital component in improving the health and well-being of people around the world”, the final sentence gives away the underlying sentiment of bootstrapping: supporting “individuals in taking ownership of their mental health and well-being” (emphasis mine).

The “social health” component from the Transdomain Model of Health is missing from “lifestyle psychiatry”, even though addressing social health will make it much easier for people to succeed in the “lifestyle psychiatry domains”:

It’s much easier to get physical exercise when there are generous green spaces, plenty of intact sidewalks, and public safety isn’t a concern. Healthy diets and nutrition are easier to achieve when fresh food is available and affordable. It’s easier to be mindful and take yoga classes when you don’t have to work two jobs to make rent. People sleep better when there’s no noise pollution; what if the affordable housing wasn’t only close to airports, trains, and freeways? Neighborhoods with “third spaces” make social relationships more likely to bloom.

To be fair, the lifestyle psychiatry authors do write of “consultation and leadership to governments, corporations, and health care systems” and informing “public education programs and community planners to support the creation of healthy communities [and] employers in creating healthy workplaces”. Their definitions, though, ultimately focus on individuals and do-it-yourself interventions with some consultation with your local lifestyle psychiatrist. (And, to be clear, I’m not saying that systems are the only issue. People do still need to make their own choices, but we can shift systems so it’s not as hard for people to make healthier choices. Life is already hard enough.)

Seattle was not anywhere near the path of totality for the total solar eclipse today. Over lunch I watched part of NASA’s live broadcast. And what a mush ball I am: I cried into my meal as I watched the skies turn to black, heard the crowds cheer and gasp, and saw the dancing corona of the Sun.

I’m not so naive to believe that being in community solves everything. However, I do believe that being in community–contributing to social health–can powerfully change the way we view and feel about ourselves, others, and the world around us. Millions of people witnessed a total solar eclipse in person or in two-dimensions today. I’m pretty sure I wasn’t the only one who cried while watching the broadcast. Three things had to be in place for this celestial event to occur: The Sun, the Moon, and the Earth. To witness this stellar occasion, we all had to be on the same planet. Maybe this is naive: I’d like to think that the shared experience of a total solar eclipse boosted our planetary social health. And, as a result, we individually experienced higher mental health today.

Categories
Education Medicine Policy Public health psychiatry Systems

What is Mental Health? (02)

To continue from my last post about “what is mental health?” and “what am I doing?”, let’s look at another figure from the paper What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey:

Figure 2C

This model argues that an individual’s mental health isn’t the sole product of that single person (because, yes, things are complex). “Society” also contributes to and affects a person’s mental health.1

The Covid pandemic provided plenty of empirical evidence that “society” has enormous influence on the mental health of individuals. Over a third of young people reported “poor mental health” and nearly half reported they “persistently felt sad or hopeless” in 2021. There were nearly 30,000 (!) more deaths related to alcohol when comparing 2019 to 2021. Two out of every five adults reported “high levels of psychological distress” at some point during the pandemic.2

The pandemic isn’t the only example of the power of “society” on mental health. Survivors of mass shootings can develop psychiatric symptoms or disorders. Residents of Flint, Michigan, could only access drinking water contaminated with bacteria, disinfectants, and lead. This contributed to elevated rates of psychological conditions like depression and PTSD. Poverty increases the likelihood of depression and anxiety.

“Imagine how many people I wouldn’t need to see if people never experienced homelessness!” I mutter (or exclaim) at least once a month. It’s not just homelessness: It’s working three jobs to make rent; it’s trying to keep the family fed and housed when one parent has major medical problems; it’s trying to leave an abusive partner; it’s trying to keep things together when a family member has an alcohol or gambling problem. Because much of my career has been in the “deep end” of the system, I often witness how misaligned and rigid institutions often bruise and scar the psyches of individuals and populations of people.

Maybe context matters more in psychiatry than in other fields of medicine. When I think, “What am I doing?”, I often wonder if I should work “upstream” in prevention and early intervention to help change these contexts. This includes advocacy for action that is outside the purview of medicine, such as lowering barriers to housing or increasing regulation of firearms.

Some physicians (and others) have argued that doctors should “stay in our lane”, that we should focus on treating conditions that we are trained to treat. Medical school didn’t teach me how to prevent psychotic disorders; it trained me to identify and treat schizophrenia. In residency I didn’t learn how to develop policy and programming to prevent war and rape; I was trained to provide care and support to someone with PTSD. I can help someone choose to put their gun away so they don’t shoot themselves; I don’t know how to organize people to persuade elected officials to change gun regulations.3

Of course, there’s a middle ground. My clinical experience and expertise give me the anecdotes and data to advocate for system changes. These system changes can improve the health of individual people. Furthermore, there are real people who have real psychiatric problems who need real help right now. As Paul Farmer said,

To give priority to prevention is to sentence them to death—almost to urge them to get out of the way so that the serious business of prevention can start.

I once worked for a medical director who often said, “I’d love to work myself out of a job.” It sounds disingenuous, but it’s true: I completely agree. How wonderful would it be if fewer people experienced psychological distress and problems with living! (Given the ongoing shortage of psychiatrists and other mental health professionals, this would be a win for literally everybody.) What if people didn’t believe that suicide was the best option? Or if people didn’t have to grapple with unending worry about where they will sleep tonight or when their next meal would be? I wholeheartedly concede that crafting legislative language and designing policies and programs are not my strengths. However, it also makes little sense to me to keep my head down and simply treat illnesses and suffering that can be prevented. Things don’t have to be this way.

(1) Again, if we’re going to be picky about words, I prefer the word “context” over “society”. “Society” suggests something uniform, when there exist microcultures within one society. For example, I’ve worked as a homeless outreach psychiatrist in New York City and Seattle. In New York I wore bright blouses with large ascots. In Seattle I wear dark hoodies. Same job, same society, different contexts.

(2) We can argue about whether these reports of distress and their associated behaviors reflect “mental illness” versus “mental unwellness”, in reference to part one of this series.

(3) While media reporting often focuses on guns and homicide, firearms cause more suicides than homicides.

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Consult-Liaison Education Medicine Public health psychiatry Reading

What is Mental Health? (01)

To try to answer the perennial question I ask myself (“what am I doing?”), I recently read this 2015 article, What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey.

As a psychiatrist1, do I treat mental illness? What is mental illness? What is mental health?

The paper comments on the ambiguity in the definition of “mental health”:

Mental health can be defined as the absence of mental disease or it can be defined as a state of being that also includes the biological, psychological or social factors which contribute to an individual’s mental state and ability to function within the environment.

Upon reading this I recognized that I define “mental health” according to the second definition, “a state of being…”. This also explains why I internally bristle when people say “mental health” when they actually mean “mental illness”. (Example: The Lancet Commission on ending stigma and discrimination in mental health.)

Figure 2B, the Two Continua Model, resonates with me:

There are people with diagnoses of significant mental illnesses who have “high mental health”. (If we’re going to be picky about words, I’m not sure that I like grading mental health as “high” or “low”. Maybe “well” versus “unwell”? It is more common to hear “I’m physically doing well,” rather than “My physical health is high.”)

Consider the person with a diagnosis of schizophrenia who has been hospitalized multiple times in the past. However, now they go about their lives and only make contact with their healthcare team every few months for routine check-ins.2

Then there are people with no diagnosable mental illness who have “low mental health”. Consider the many people who felt psychologically unwell during the Covid pandemic.

I started doodling to try to determine where psychiatry should intervene along the axes of mental illness and mental wellness:

I have yet to come up with any convincing answers. This doodling did offer clarity, though:

My professional interest has been the diagnosing and treatment of (often severe) mental illness. There are many reasons for this. One compelling reason is that the severity of symptoms makes it unmistakable that professional intervention is warranted.3

Only after years had passed did I recognize that this worldview is why I chafed at some requests patients brought to me early in my career. I once went through an entire diagnostic interview with a guy who worked as a game designer. Nothing came up; according to the Two Continua Model, he had neither a mental illness nor low mental health. Only at the end did he reveal why he had sought care from a psychiatrist: “My girlfriend takes Prozac and it made her more creative. I thought that if I take Prozac, that might make me creative, too, which can help me with my work.”

My goal was to diagnose and treat a mental illness. His goal was mental enhancement.

Are these two goals mutually exclusive? I don’t think so, though I want to noodle on this more.

The history of psychiatry holds these two goals in tension, too: On one end are the state psychiatric hospitals (also called asylums) where some people with severe symptoms (or not) were held (warehoused?) prior to the elimination of these institutions. On the other end are the psychoanalysts, where the typical patient was “a college-educated, upper-middle class professional who paid for service out of pocket.”

More to follow as I continue to wonder what I am doing.

  1. It was never part of The Plan to become a psychiatrist. This is part of the reason why I ask myself the perennial question, “What am I doing?”
  2. When asked, “What is your best life?”, no one responds, “I want to spend as many precious moments of my existence in hospitals and clinics.”
  3. A choice quote from the paper that highlights why I personally like clarity about where professional intervention is warranted: “Lots of things can cause people problems—poverty, vices, social injustice, stupidity—a definition of health should not end up defining these as medical problems.”