Category: Education

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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”.

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Consult-Liaison Education Medicine Observations Reading

Hoping for Hope for Psychosis.

The American Board of Psychiatry and Neurology (ABPN) is running a pilot project: Psychiatrists and neurologists can read a set of articles and answer mini-quizzes over the course of a year instead of taking a multiple-choice exam. If the physician answers enough questions correctly in either activity, then this supports the application for board recertification.[1. To be clear, I feel frustration with the American Board of Psychiatry and Neurology and their board recertification procedures. This “read articles and take mini-quizzes” is an encouraging improvement, but there are other aspects of board recertification that give me heartburn. This is why I am also a member of the National Board of Physicians and Surgeons.]

I am enrolled in the “read articles and take mini-quizzes” pilot. One of the mandated articles is “Improving outcomes of first-episode psychosis: an overview“. One of my professional interests is psychotic disorders (e.g., conditions wherein people report hearing voices and beliefs that do not appear rooted in reality). If you share that interest, you may find this article informative, too.

Note I said “informative”, not “encouraging”. Here are a selection of statements I found notable in the article:

Psychotic disorders such as schizophrenia are common, with 23.6 million prevalent cases worldwide in 2013. One in two people living with schizophrenia does not receive care for the condition. The recovery rates… and associated disability… following a first episode of psychosis have not improved over the past seventy years under routine clinical care. Although existing psychopharmacological treatments alone can reduce some symptoms, they have little impact on the outcome of the illness.

Oof. This is the first paragraph of the article! None of the statements surprise me, but when they are all put together like that… well, it makes me wonder: “When are we going to get better at this? When will we consistently help individuals with these conditions?”

At the moment, there are no approved [prevention interventions for individuals who are clinical high risk for psychosis] that have been shown to reliably alter the long-term course of the disorder.

Sigh. This speaks to population-level data. This means that we—the individual at high risk, the family and friends of this person, and any professionals involved at the time, if we happen to meet this person—grope around as we try to minimize the risk of illness. Maybe our efforts will work for This Person, but maybe they won’t for That Person. So we continue to work and hope.

The detrimental impact of illicit substance abuse on the long-term outcome of psychosis is well known, with a dose-dependent association.

Here in Washington State, we see a lot of people with psychotic symptoms who have used or are using methamphetamine. It ruins minds. I wish people would stop smoking/snorting/injecting it.

Marijuana is legal in this state and there is some evidence that cannabidiol (CBD), a compound found in marijuana, may reduce psychotic symptoms. Delta-9-tetrahydrocannabinol (THC), also found in marijuana, can induce psychotic symptoms. This is problematic. Companies sell CBD on the internet and I have concerns about how people will run with this preliminary data.

[There is a] lack of stringent evidence for a robust effect of antipsychotics on relapse prevention in the long term….

The article summarizes evidence that suggests that antipsychotic medications may simply delay the relapse of psychotic symptoms, rather than prevent them from reappearing.

One of my early jobs was working in a geriatric adult home. My work there taught me that people with psychotic disorders can and do get better. The burdens of antipsychotic medications—paying for medications, the actual act of swallowing the pills every day, the side effects, some mild, some intense—add up. I was fortunate to work with some people to successfully reduce the doses of their antipsychotic medications and, in some cases, stop them completely! (There were also at least one instance when tapering medications was absolutely the wrong thing to do; that person ended up in the hospital. I felt terrible.)

When I reflect on that time, there were no guidelines about this. These decisions to taper medications—always with ongoing discussion and with the individual’s consent—were just an effort to “first, do no harm”. Context matters: I used as much data—from the individual, family and caregivers, and the literature—as I could find before embarking on deprescribing. Was I naive and reckless? Maybe. Was I just lucky? Maybe? Was I doing the best that I could with the information I had? I think so.

Schizophrenia features are strong predictors of poor long-term outcomes… when communicating with patients, it may be preferable to use the broader term psychosis rather than schizophrenia….

As far as I know, schizophrenia is the only psychiatric diagnosis that includes the criterion “Level of functioning… is markedly below the level achieved prior to the onset“. Even the neurocognitive disorders (dementias) don’t explicitly comment on a decline of “level of functioning”.

One wonders if the long-term outcomes in schizophrenia might be even just a little bit better if those of us who give the diagnosis of schizophrenia believed that people with this condition could get better. Do we, as a group, give this diagnosis out of resignation? And what message does that send to individuals experiencing these symptoms?

And what about that recommendation that we don’t discuss “schizophrenia” with individuals with psychotic symptoms? Indeed, for individuals presenting with “first episode psychosis”, this counsel is prudent. People with psychosis do get better. But, again, do we avoid using the term “schizophrenia” because of the connotations associated with that word? “… we don’t think you will ever get better.”

Maybe this is a circular argument: The reason why a decline in function is part of the definition of schizophrenia is because there is a decline in function in people diagnosed with schizophrenia.

But what about the people who meet all criteria for schizophrenia who get better?

The people who discern the pathophysiology of schizophrenia shall win the Noble Prize, for they will have figured out how the brain works. And perhaps, by that time, the articles about psychosis will give us all hope.

Categories
Education Nonfiction Reading

Books I Read in 2018.

I know this post is late (i.e., “These are the things I did in 2018” posts usually appear in December), but perhaps some of the books I read in 2018 will make it onto your reading list for 2019.

Radical Dharma: Talking Race, Love, and Liberation. I didn’t know what to expect when I picked up this book. Because the authors are people of color, they bring a different perspective to Buddhist thought and practice. In some ways, this was a refreshing change from much of published the Buddhist literature (i.e., written by white authors, or written by Asian authors who seem to have a white audience in mind). The authors also share personal anecdotes about their journey in Buddhism that may resonate with readers of color.

The Nonviolence Handbook: A Guide for Practical Action. This was the most compelling book I read in 2018. This slim book offers both concrete suggestions about how to practice nonviolence in daily living and how individuals (often Gandhi) applied nonviolence principles in history. I found this book inspiring, challenging, and meaningful. It also reminded me that I should not take cooperation for granted.

On Tyranny: Twenty Lessons from the Twentieth Century. This book is definitely a “handbook”: It is small and to the point. The table of contents alone provide useful guidance on what we all can do every single day to support our democratic society. I appreciated that the book does not rely on fear alone; it empowers the reader to take action in the face of uncertainty.

Dreams from My Father: A Story of Race and Inheritance. This book pairs well with the next book (Hillbilly Elegy). Obama’s writing reveals a thoughtful and idealistic perspective. He wrote this years before he served as President and I found myself recognizing elements of his character as President in this book. It is a story of a man trying to learn about himself and his beliefs in a world that passes judgment on him because of his heritage and skin color. It also highlights the importance of his relationship with his mother.

Hillbilly Elegy: A Memoir of a Family and Culture in Crisis. I read this after Dreams from My Father and, in many ways, I felt like I was reading the same tale with different details. Vance also tells the story of his efforts to learn about himself and his beliefs in a world that passes judgment on him because of where he was born and raised. Vance, too, highlights the importance of his relationship with his grandmother. Because Vance and Obama have different political ideologies, these two books show how, despite our beliefs, we share more in common than we allow ourselves to believe.

Silence: The Mystery of Wholeness. I picked up this book with hopes of learning more about how to find or create silence in a world that seems full of sonic garbage. This was the most “woo woo” book I read all year. I often wrote question marks in the margins. I intend to re-read this book at some point; I may always find it esoteric. I found the ideas of different silences (e.g., the silence within our hearts versus the “big” silence of the universe; how silence is always with us) useful for my own application.

The Girl on the Train. I rarely read fiction, so this was a treat. I picked this up on a public bookshelf for airplane reading. The story was engrossing, though I couldn’t help but think about the lack of coping skills the characters demonstrated. I also discerned the identity of the villain early on, so the “twist” not surprise me. The book nonetheless makes for fine brain candy.

Falling Leaves: The Memoir of an Unwanted Chinese Daughter. This book was also a selection for airplane reading. The intercultural issues of the memoir are familiar to me and the storytelling is satisfactory. This memoir seemed to lack the depth of self-reflection as seen in the Obama and Vance memoirs. I wanted to learn more about how she grew and understood herself as an individual as a result of her experiences with her stepmother.

Silence: The Power of Quiet in a World Full of Noise. This was yet another effort to apply more silence in my life. This text is similar to other works by Thich Nhat Hanh, though does comment more on cultivating silence within (which, in some ways, paired nicely with the Sardello book above on silence). Did I learn anything new? No. Did it nonetheless bring me comfort? Yes. This book was another reminder to me that we often have to generate our own silence, particularly when there is a lot of noise “outside” that we cannot control.

Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others. I read this in anticipation of a talk from the author, Laura van Dernoot Lipsky. Many of the examples in her book come from her previous clinical work in Seattle, so the book felt particularly familiar. The book offers validation to all of us who work in clinical settings. I was hoping for more commentary on how we can adjust or shift systems to better support people who work in human services; the book focuses chiefly on what the individual can do. I also hoped that the book would offer a more evidence-based framework for these individual interventions, though also appreciate that there are spiritual aspects of trauma work that are difficult to measure. Laura is a compelling and energetic speaker. You can watch her TED talk.

Extreme Government Makeover: Increasing Our Capacity to Do More Good. I received this book from a colleague, who received it from the author for free! (My colleague and I both work in local government and when she asked him if he could provide the books at a discount for the staff, he sent a stack of books to us at no charge.) The major premise of the book is the reduction of waste: Reducing the amount of time between tasks (much of which is waiting, with no action happening); eliminating bottlenecks (e.g., where only one person is the “decider”); and minimizing processes that only serve to prevent lawsuits. I suspect that selection bias is at play, though: The people who choose to read this book are probably already aware of how to make things more efficient.

Here are all the books I started in 2018, but did not finish:

A People’s History of the United States. I’m actually over halfway through this book. I found myself getting angry while reading it, though, given the current context of the federal administration in the United States. Some of the events described in the book were similar to the ideas coming out of the current White House. I like reading and don’t need to experience more anger than necessary. I do want to finish this book, just not now.

The Making of Asian America: A History. I found myself getting angry while reading this one, too, so I put this one down. I like that the author discusses the experiences and events of different Asian groups, as, indeed, Asians are not all the same. I will get back to this one, too.

The Art of Memoir. I want to write a book, and that book is a memoir. Writing is already difficult, but the writing for this memoir presents particular challenges. I hope to learn from the mistakes and experiences of others. However, reading about memoir writing takes time away from actual memoir writing. Sometimes we fool ourselves into thinking we need to learn from others when, in fact, we just need to do the work.

The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are. I had never read a book by Brene Brown, though I enjoyed listening to Krista Tippett interview her on the podcast On Being. The book is like a personal cheerleader, which is fine, though that’s not what I needed or wanted.

Good Prose: The Art of Nonfiction. I enjoy reading good sentences. I continue to strive to craft clear, meaningful sentences because I want to write stellar stories. As I noted above, though, sometimes we just need to do the work.

Chinese Culture and Mental Health. While Western psychiatry is getting better at acknowledging the role of culture in the manifestation of thoughts, emotions, and behaviors, it still ain’t great. This book is an academic textbook, so while it is informative, it isn’t the most exciting reading. I will finish this one, too, though it may take a while.

How to Measure Anything: Finding the Value of Intangibles in Business. I picked this up primarily to help me think about my clinical and administrative work in a different way. I have already learned interesting perspectives about measuring seemingly immeasurable things in the first quarter of the book. This book requires a level of concentration that I often did not have by the end of the day. This is a book I want to finish, but it will take time.

If you want to share with me what books have changed your life for the better or made you think about the world in a different way, let me know (e-mail, Twitter, Facebook).

Categories
Education Lessons Nonfiction Reflection

Uncomfortable Thrill.

When I walked through glassware sections of stores as a child, my body buzzed with distress and delight. There were only two ways to ease this anxious discomfort:

  1. Fling my arms out and knock over all the glass to see, hear, and feel the pieces shatter; or
  2. Keep my arms tightly by my side and ensure that nothing above the soles of my shoes touched any objects in the store.

I always chose the second option. The urge to fling my arms out to knock over crystal and glassware has diminished with time. If I’m honest, though, the uncomfortable thrill persists.

That same uncomfortable thrill pulsed through me when the loaded guns rested in my hand.

It didn’t matter that I received a private didactic (with a white board![1. The white board didactic included four rules: (1) All guns are always loaded. (2) Keep finger off trigger until ready to fire. (3) Be aware of target and what’s behind it. (4) Don’t point at anything you’re not willing to destroy.]) about gun safety from someone I know and trust (who also happens to work as an emergency physician). It didn’t matter that we were at a pistol range where safety was paramount. It didn’t matter that I had close supervision for my first experience in shooting firearms.

The paper target revealed that my initial shots were the most accurate; the subsequent shots often drifted farther and farther from the target. Maybe my hands and arms suffered from fatigue. Maybe my uneven breathing made my body needlessly tense. Maybe my safety glasses got too foggy from perspiration.

Maybe it was the National Geographic article about a young woman’s face transplant due to a self-inflicted rifle wound that I had read just the day prior. Maybe it was the imagery of the assassination of President John F. Kennedy and the later murder of Lee Harvey Oswald that I saw at The Sixth Floor Museum.

Maybe all the stories I remembered from my work as a psychiatrist freaked me out.

Maybe it was all the stories I never heard or have yet to hear.

It happens so fast: Finger is off the trigger. Finger then rests on the trigger. Finger flexes.

BANG!

The bullet is gone. My body lurches with the recoil. The bullet casing bounces off my shoe. I only see the puff of pewter smoke when I lower my arms.

  • How much time passed between the time she loaded the gun and when she fired it at her chest?
  • Did she hesitate before she put her finger on the trigger?
  • How many times did he try to pull the trigger before putting the gun down?
  • Did he ever put his finger on the trigger before he pulled the barrel of the gun out of his mouth?
  • Did she ever touch a gun before the day she tried to kill herself with one?
  • Did he imagine what the BANG would sound like within his skull?

The power of the weapons spooked me.

My hands weren’t shaking, but my fingers could not push the 9mm bullets into the magazine. My hands felt weak.

More than once I walked away, pulled the safety glasses off my face, wiped the sheen of sweat off my forehead with my forearm, and then jumped up and down several times.

I never felt any urge to turn the guns on myself, though the uncomfortable thrill reminded me that I could. Others who are unable or unwilling to resist that uncomfortable thrill could indulge that urge, whether against themselves (more common) or against others (much less common). The uncomfortable thrill may not feel so uncomfortable when one is intoxicated. Or angry. Or hopeless.

It could happen so fast.

Yet, I quickly recognized the appeal behind shooting. Guns are tools. The anatomy and mechanics of firearms are interesting. Learning how to aim and hit targets with high accuracy is satisfying and rewarding. Achieving mastery over such powerful tools is thrilling.

I am grateful that I had the opportunity to learn how to shoot pistols. It was fun, though I must confess that it was not as fun as I had anticipated. Thoughts of death and injury from suicide rarely left my mind, which added elements of stress and sadness. Jumping up and down and taking deep breaths could only do so much.

The power of guns freaked me out. It was only the next day that my body finally stopped buzzing with distress and delight.

Categories
Education Medicine Nonfiction Reflection Systems

I Have No Plan.

We learn about SOAP notes early in medical school:

S = Subjective, or what the person reports to you

O = Objective, or the data you gather from the person (vital signs, physical exam, lab studies, etc.)[1. We’ll put aside for now the discussion of the problems with labelling these sections “Subjective” and “Objective”.]

A = Assessment (a diagnosis and formulation based on the Subjective and Objective data)[2. We’ll also put aside for now the potential problems that arise at the intersection of billing and diagnosis.]

P = Plan (the next steps or recommendations that occur as a result of the Assessment)

Most medical notes, regardless of specialty, setting, or length, follow this SOAP format.

While recently typing up some notes, I blurted to my colleague, “What I really want to write under the ‘Plan’ section of my note is, ‘I have no plan’. Can I do that?”

Sometimes the Plan is direct and clear:

S: Mr. Doe reports that he hasn’t heard voices in three days. He finds it easier to read books. He denies side effects from medicine.

O: He isn’t talking to someone who isn’t there. He’s not demonstrating tremors. He’s showing more emotional expression in his face.

A: A psychotic disorder that could be due to This, That, or The Other Things.

P: No changes in medication. Continue to encourage activities he enjoys. Cheerlead his ongoing efforts to monitor his own progress. Follow up in a few weeks.

Sometimes I have a Plan, but it’s not a Plan I write down because the next steps or recommendations are beyond our control:

S: Ms. Doe reports that she uses methamphetamine to help her stay awake at night. She fears that if she falls asleep, men will hit or rape her. She still hears voices. They have gotten more intense since she left her foster family a year ago, as a member of the foster family was molesting her.

O: She’s distracted, looks exhausted, and, since she doesn’t have a safe place to stay, has little interest in reducing or stopping her use of methamphetamine.

A: Methamphetamine use disorder. Some flavor of a trauma- or stressor-related disorder. Maybe an anxiety disorder? Maybe a psychotic disorder that could be due to This, That, or The Other Things?

P: (1) Ensure that people have safe places to live. (2) Stop human beings from sexually assaulting other human beings. (3) Instill proper ethics and morals into all of humanity.

Then, there are times when the Plan doesn’t include concrete steps that will guarantee forward movement:

S: Mr. Doe was reluctant to talk to me. He only shared that his words are potent and, if he misspeaks, my face will melt off. He said that he doesn’t want to hurt me or anyone else with his power. My efforts to inform him that my face will remain intact were unsuccessful.

O: He’s eating, he’s sleeping, he avoids other people, and this is the most he’s spoken to anyone.

A: Probably a psychotic disorder due to This, That, or The Other Things?

P: ???

Since I have to write something, the Plan in these situations usually looks like this:

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P: Continue to build rapport as tolerated. Gather more history. Will try to talk to him again in X amount of time.

The most difficult notes to write are those when I know I have no plan. This is distinctly different from not knowing what the Plan should be. (This is a function of time and experience, of knowing what I don’t know.) These situations usually involve a combination of the last two situations I described:

S: Ms. Doe said that there is a dead baby inside of her. Records state that she has reported this for the past four years, though there is no evidence that she has been or is pregnant. She was the victim of a significant assault five years ago; she sustained head trauma from this event, which many believe is the cause of her erroneous belief. She visits emergency departments multiple times a week due to her belief that there is a dead baby inside of her. She has assaulted both of her parents multiple times, so they have filed “no contact” orders against her. Because she now has no place to live and her anxiety about a dead baby inside of her persists, her behaviors sometimes result in law enforcement encounters, which land her in jail. She has avoided psychiatric services because she insists that her belief is true.

O: When she does talk, she speaks with dread and grief about a dead baby inside of her. Other times, she screams, demanding that people leave her alone. When she menstruates, she smears the blood all over herself while crying, mourning the loss of what she believes is her dead baby.

A: A psychotic disorder probably due to the head injury, but maybe due to Other Things?

P: … [I have no plan. I just don’t.]

The best Plans are those constructed with the person in question. Unfortunately, Ms. Doe usually doesn’t have a plan, either. So, I write down the little I can actually do:

P: Work with team to build rapport as tolerated. Find out what else she cares about. Work with other systems to create a plan to help reduce her distress without causing more trauma.

… and hope that patience and persistence will reward us in the future. Because sometimes hope seems to be the only thing we can do.