Category: Education

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Consult-Liaison COVID-19 Education Medicine

Vulnerability and Resilience.

We had our medical staff meeting on Friday, which was the first time we had all convened since the COVID-19 epidemic was announced in Seattle-King County.

I shared with the team the following framework, which is from a paper about demoralization.[1. It is common for other medical specialties to request a psychiatric consult for a patient who seems depressed. Consultation psychiatrists often learn that it is demoralization, not depression, that results in consult requests. (Though demoralization and depression share features, most psychiatrists agree that they are distinct conditions. These distinctions are discussed further in the paper.)]

The authors note that:

Demoralization refers to the “various degrees of helplessness, hopelessness, confusion, and subjective incompetence” that people feel when sensing that they are failing their own or others’ expectations for coping with life’s adversities. Rather than coping, they struggle to survive.

and later comment that “[a]cknowledging suffering and restoring dignity are potent in strengthening a patient’s resilience to stress.”

This is the valuable table from the paper:

During this extraordinary time of the COVID-19 pandemic, this framework may help you, whether you work in medicine or not. Sometimes the act of putting words to our emotions can alleviate our discomfort and help us feel more empowered.

We may all feel overwhelmed with the emotions and experiences on the left side of the table. Many, if not all, of us during the past few weeks have felt confused, helpless, and resentful. We have felt lonely and isolated, though we may recognize that we’re lonely and isolated all together. Sometimes fear gets the best of us and we wonder if anything we do matters. Vulnerability is often an uncomfortable position.

Remember that there are things we can all do to nudge us over to the right side of the table. Thanking others helps us reconnects us with people. Looking for the helpers can inspire us and give us hope. Taking a breath (or two or three) and slowing down helps us pursue clarity so we can find the signal in the midst of all the noise. The choices we make in each moment can help us recognize and cultivate our own courage and resilience. How we choose to react to what’s happening around us can shape our purpose. Do we react in anger or kindness? Do we have faith that we will do the best that we can in face of uncertainty, or do we assume the worst in others and ourselves?

To those of you who work in emergency departments and hospitals, regardless of your role, we thank you for your courage and efforts. We in outpatient settings are doing our best to keep people healthy and out of EDs. We all look forward to the time when this will be just a memory.

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Education Seattle Systems

Recommendations to other physicians from Washington re: COVID-19.

This post isn’t polished, but (a) it seems important to get this information out and (b) it also helps me feel like I have some control over something:

I work as the medical director for a non-profit agency that serves people who are currently or formerly homeless.[1. This post is NOT on behalf of my employer! I am writing as a private citizen who has opinions.] I am trained as a psychiatrist and have previously worked in local government. I live in the county in Washington State where people have died from COVID-19.

Here are my recommendations for other physician leaders in other regions, particularly those who work in outpatient, non-profit settings. I hope this information can help you if once COVID-19 arrives in your area.

Start talking with other physician leaders that intersect with your work now. Talk about how you all will coordinate together. How can your teams all work together to ensure that only people who need ED-level services are sent there? What sort of screening will you all do? If people who don’t have homes need to self-isolate, where can they go? Establish a communication system now because when COVID-19 arrives, you don’t want to fumble through that. If you haven’t met these other people yet, meet them now.

Start talking with physicians who work in your local government. My observations thus far are that physicians in government haven’t been active in planning for systemwide medical issues, and not because they’re not interested, but rather because they are overwhelmed and there’s not enough of them. Start asking questions like: if people who are homeless need quarantine, where should they go? has the city or county started talking with the hospitals to determine a system of where people with COVID-like symptoms should go? who will get tested? is there a centralized phone number clinics can call to alert county authorities of outbreaks? what sort of communication is the city or county having with the state?.

Keep up the advocacy with state and local partners with questions related to system processes. The state and local partners likely won’t have answers, particularly if you serve underserved patients. Since COVID-19 is affecting everyone, governments are thinking about the majority of people, many of whom are the “worried well”, can self-isolate, can go see their own doctors, etc. People without the same resources can’t do the same prevention and early intervention activities, so it is vital to keep following up with government partners so they don’t forget about these underserved populations. (This also includes populations that may not seek health care services, like immigrant and refugee populations.) If you can keep up the questions to your physician partners in government, they will feel empowered to keep asking their partners (e.g., state and federal agencies) for information.

Start teaching stuff to your non-medical partners. Sometimes physicians and nurses forget what we know; we think everyone knows what we know. Agencies that serve homeless populations often don’t have medical staff, so their leadership and line staff may have questions like, “Will an air purifier eliminate COVID-19?” or “Will hydrogen peroxide kill COVID-19?” People may not know HOW to wash their hands. Advocate with your agency leadership to get hygiene supplies now (because most of the suppliers locally are sold out) and make it easy for your staff to practice good hygiene. And don’t make assumptions that people know how to do hygiene stuff.

A small minority of people will do things you won’t like. There are people calling health care agencies pretending that they are the WHO or CDC and are asking for financial information so they can steal money. Supplies, like face masks, may suddenly go missing. Prepare for these sort of disappointing behaviors.

You can’t overcommunicate. In the face of uncertainty, frustration arises. Don’t lie, either; tell people what you know and don’t know. That way, they will be more likely to trust you when you do have recommendations.

Support your staff. You can’t rely on your staff to take care of other people if your staff don’t think you are taking care of them. We heard a comment today during a phone call that an estimated 40% of staff will be out of the office due to illness. Some may also call out because of fear. We can appeal to the better natures of our teams, but they won’t rise to the challenge if they think we don’t care about them. And if they don’t think we don’t care about them, then they won’t have the emotional and cognitive capacity to care for patients. (This applies to local government, too: They must take care of the agencies that provide services on their behalf, or otherwise the agencies will feel unsupported and may not extend themselves.)

People are expressing and demonstrating anxiety, which is fine—there are reasons to worry. But there are things we can do as leaders to acknowledge and mitigate that anxiety. Start now.

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Education Lessons Nonfiction Policy Reflection Systems

What I Learned in Government.

It’s been nearly four months since I posted something here. Don’t be fooled: The lack of words here did not mean an absence of word salads tossing about in my head.

I recently resigned from my job. (All The Things related to that contributed to my silence here.) My job had two parts: One involved administrative work as the behavioral health medical director for local government; the other involved direct clinical service in a jail. I was in that job for over five years. It took me about two and a half years to figure out what an administrative medical director does. (As the process of becoming a doctor involves frequently feeling incompetent, this discomfort wasn’t new to me.) Now that I’m on the other side of this job, here’s what I’ve learned:

I believe government can do good things. You know that stereotype that government employees are lazy? I did not find that to be true. Every organization has a proportion of staff who do not seem motivated or interested. The proportion, in my experience, does not seem higher in government. If anything, many of my colleagues came to government with eager hopes of improving the community. They came in early, stayed late, and worked on weekends. They convened groups with opposing viewpoints, advocated for different populations in the region, and expressed dissent to people in power. They sought out and willingly worked on complicated problems. They demonstrated the humility that comes with the realization that tax payers are funding their salaries.

I do not enjoy the game of politics. Some people love it! They enjoy the contests of status, flaunting their connections, and attacking perceived enemies in public forums with the brightest of smiles. Sometimes people asked me to speak, not because they cared about the content of my words, but because of my credential as a physician. (“Let’s trot out The Doctor.”) I grumbled about “perception management”; often it seemed that the surface sheen mattered more than the substance underneath. (On the other hand, it is likely that my glittery MD credential is what allowed me to say to superiors that poop will never develop a patina. It is unfair that systems often value specific people more simply because of the letters after their names.)

Government work has made me both more and less patient. It takes time to elicit ideas and information from “stakeholders”, community members, and others. People want to and should be involved if a policy or program will impact their lives. They share perspectives that government never thought to consider. I respect that process. I am less patient with the nonsense people and systems can generate to subvert fair processes. Some people are more prone than others to misuse power. That’s hard to watch in a system like government, which has access to and authority over so much money… and, in our current system, whoever has more money almost always has more power.

I learned a lot about laws and regulations. I came to appreciate the value of regulations, though they tend to address the lowest common denominator. Government spends most of its time aiming low to define the floor instead of inspiring people to elevate the ceiling. (I wrote more about this here.)

Government administrators forget what happens in direct service. Though many people in government once provided “front line” services—as attorneys, social workers, counselors, activists, whatever—many of them seem to forget the challenges of systems that are intended to help people. This includes the thousand little cuts of too much paperwork and the major crises of people dying due to missing or underfunded services. My opinion that all medical directors should routinely provide direct clinical service has only gotten stronger with this experience. Someone has to inform the others at The Table what’s going on outside.

Systems are made of people. Contemporary discourse often focuses on systems, not people… but people make up systems (i.e., individuals create, operate, and maintain systems). As such, single individuals can still have significant impacts on systems. This includes grinding things to a halt… or breathing life into new programs. (This is where political gamesmanship can be useful.) The hierarchical organizational chart can lead people who are “lower” to think that their efforts don’t matter, but that’s simply untrue. Systems can change because people can change… whether that’s because people actually change their ideas and behavior or people in certain positions leave.

I am deeply grateful for the opportunity to work in government. I never thought I would work as a civil servant (and, in fact, there was a time when I said I’d never work for government… which is why I’ve stopped making five-year plans). If for nothing else, now that I’ve been on the inside, I can use that experience and knowledge on the outside.

The outside suits me better. So it’s time to go back.

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Consult-Liaison Education

Most People Do Okay Most of the Time.

Because May is Mental Health Month, I was asked to present information about mental health to a lay audience. This is both an exciting and daunting task. I imagine it’s like asking someone to talk about fish. There are so many kinds of fish! They live in many habitats! Some of them look more like snakes than fish! There are so many directions to go.

I have given a “psychiatry 101” talk to many non-clinical audiences in the past. While reviewing my notes, it became clear that, while this presentation offers useful introduction, the underlying message is that psychiatry focuses on pathology. (This is a common theme in medicine: Doctors are often much better at looking for and finding things that are wrong than at pointing out and supporting things that are going well.)

So, here are three things about psychiatry that don’t focus on pathology:

People are resilient. I remain amazed with the capacity people have to take care of themselves and others when everything is falling apart.

Even though the majority of people experience terrible trauma—war, rapes, natural and unnatural disasters, etc.—most of them will not develop post-traumatic stress disorder. Most people at some point will experience heartbreaking grief following the death of a loved one, but the vast majority will not develop major depression or complicated grief.

People go to work, take care of children, and support their friends despite hearing disturbing voices, thinking about suicide, and feeling unsafe in public. They find ways to help themselves that have nothing to do with formal psychiatric interventions: The man hearing disturbing voices might put on headphones and play the same song over and over again. The woman thinking about suicide might sign up for an extra volunteer shift at the animal shelter so she is around other people. The military veteran might sit in the rear corner of the movie theatre.

Most people do okay most of the time.

It’s okay to not feel good. The goal of feeling happy or serene all the time is an impossible goal. Everyone at some point thinks disturbing thoughts. Just because it seems like everyone else is happy or serene doesn’t actually mean that they are happy or serene.

While our thoughts and emotions may seem illogical at times (“why am I thinking about that?” “why do I feel this way right now?”), that doesn’t mean that something is wrong. Sometimes your thoughts and emotions are treasure troves of information: Your internal experiences give you information about the person you’re talking to, the situation you’re in, and what your next steps should be.

The definitions of psychiatric disorders are not solely limited to “not feeling good” or disliking an emotional experience. Sometimes we don’t feel good. Sometimes that lasts longer than we want. But that doesn’t mean you have a terminal emotional illness.

Most people do okay most of the time.

Behaviors serve a purpose. We all do things that other people think are weird. The spectrum of weirdness is wide, but, if we are lucky to learn more, we can find out the basis behind the behavior.

Why doesn’t she speak up more? Because she believes that no one will find her remarks helpful.

Why won’t he wear anything other than sweatpants? Because he wants to spend his money on fancy cars.

Why won’t she stop smoking methamphetamine? Because it helps her stay awake at night so the men won’t rape her.

Why does he apologize all the time? Because, as a child, he learned that if he apologized a lot, he might be able to stop his father from beating him.

Why does he say things like, “I know a lot about wind” and “I know more about drones than anybody”? I mean, who knows. Is this the only way he knows how to interact with other people? Have these sorts of boasts helped him succeed in the past in relationships and business deals?

The definitions of psychiatric disorders are not solely limited to “doing weird things”. If we do certain things that help us or get things that we want, we will continue to do those things. Sometimes we continue to do those things even when they no longer help us as they once did. But that doesn’t mean you have a terminal psychiatric illness.

Most people do okay most of the time.

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Consult-Liaison Education Medicine Reading Reflection Systems

The Challenge of Going Off Psychiatric Drugs for Psychiatry.

Here are my initial reactions to the New Yorker’s The Challenge of Going Off Psychiatric Drugs:

Which populations are most likely to receive large numbers of psychiatric medications?

The woman described in the article comes from a family of money and privilege. These individuals (and families) have both the time and money to seek out psychiatrists who practice “precision psychopharmacology”. These psychiatrists then order complicated medication regimens that ostensibly address and “correct” neuroreceptors. As a consequence, people end up taking multiple medications.

There are also individuals who do not have money or privilege, but are subjected to psychiatric services due to the concerns of the public. They may be behaving in ways that endanger their own lives or the lives of others. As a consequence, they receive medications—sometimes willingly, sometimes through coercion—that aim to reduce certain behaviors. If one medication doesn’t reduce the behavior, then more are added.

What these two populations have in common are (a) the lack of clarity around diagnosis, which often stems from (b) missing information about the person and the context in which s/he lives.

I completely agree with Dr. Frances’s comment from the article:

[There is a] “cruel paradox: there’s a large population on the severe end of the spectrum who really need the medicine” and either don’t have access to treatment or avoid it because it is stigmatized in their community. At the same time, many others are “being overprescribed and then stay on the medications for years.”

The meanings of diagnosis and treatment, particularly medications.

Some people feel relief upon learning that their symptoms belong to a diagnosis, that what they have is “real”. Others don’t want the “label” of a psychiatric diagnosis; they are not damaged human beings.

For various reasons (e.g., the current primacy of biological psychiatry, insurance reimbursement, psychiatry’s seeming inferiority complex within medicine), treatment in psychiatry is often focused on medications. This is not ideal. Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.

In the meantime, doctors recommend that people take pills. Some people view pills as a necessary intervention to keep them healthy and well. Some people view pills as a shameful reminder that there is something wrong with them that will never improve. The more pills someone has to take, the more potent the reminder that they are beyond hope or repair. Some people view pills as an external validator of their pain and suffering: “Someone else believes and understands my pain and these pills remind them and me that my pain is real.”

The pills may not be treating what psychiatrists think they are treating.

The problems with psychiatric diagnosis.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) focuses only on the “what”, not the “why”.

It doesn’t matter why someone has a depressed mood, takes no pleasure in work or play, can’t sleep, won’t eat, and feels hopeless. The underlying reason could be the cardiologist’s realization that he should have pursued his dream of becoming an architect… or it could be the threat of eviction after losing one’s job.

This affects the way psychiatrists gather a history from people seeking care. Instead of learning the context behind one’s symptoms, psychiatrists now focus on whether certain symptoms are present or absent. What matters more is that she feels paranoid, not that the paranoia started when she learned that her father was molesting her sister.

To be clear, there are some instances in which the underlying “why” doesn’t matter. If someone is terrified of flying on a plane, there are treatments (e.g., exposure therapy) that can help people tolerate plane rides without getting into the reasons why this fear appeared in the first place.

In other instances, though, the “why” is often relevant. Since our understanding of the biology of the brain and mind are limited, we don’t know if the biological properties of Medication A are more useful in military veterans who have fought in combat or if those of Medication B are more useful in women who experience major depression after the birth of a baby. Even if evidence suggests that medications aren’t the best treatment for either population, it is often the easiest intervention to deliver. This is due to the context and underlying “whys” of the health care system.

All of the other psychiatrists.

It’s true that there is scant evidence about how to taper and stop medications. It is a shame that psychiatry, as a field, has nothing to say about deprescribing. The scientific literature has plenty to say about adding medications, but nothing that extols the virtues of taking them away. There are risks to stopping medications, yes, but why are psychiatrists unimpressed with the risks of starting them? In this way we have failed not only the people who receive care from us, but we also fail the people who step in to help in our absence: Other physicians, nurses, family members, friends.

When I consider the psychiatrists I have worked with with, many of them have helped people come off of medications. They work with their patients and go through the trial-and-error process together. While they may not work in ivory towers of acclaim, they are still doing the work of helping people make informed choices about their care so they can lead healthy and meaningful lives. These are the quiet anecdotes that will never make it into the New Yorker.

Psychiatry as an agent of social control.

This is not the first time I’ve written about psychiatry as an agent of social control.

What does it mean that “antidepressants are taken by one in five white American women”? Is this a reflection of white American women? Or a reflection of the society and systems that want to contain white American women?

What does it mean that African- and Latinx-Americans are more likely to receive diagnoses of psychotic disorders? Is this a reflection of these populations of color? Or a reflection of the society and systems that want to contain these populations?

Perhaps there needs to be a “Challenge of Going Off Psychiatric Drugs” for the field of psychiatry. To be clear, there is definitely a role for medications in the treatment of psychiatric disorders, though: first, do no harm. When The Royal We have more humility about what we do and do not know, and exercise more care in current pharmacological tools, then perhaps getting on or going off of psychiatric drugs won’t be a “challenge”.