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COVID-19 Homelessness Medicine Seattle

Surge.

When I was younger, my intention was to become an infectious disease doctor. Forces, seen and unseen, pulled me into psychiatry.

My undergraduate studies were in microbiology, virology, and immunology. Had someone told me twenty years ago that I would someday use that knowledge on a daily basis, I would have shrugged and said, “Well, that makes sense. That’s the plan, right?”

Had someone told me ten years ago that I would use knowledge from my undergraduate studies during a pandemic, I would have snorted: “But now I work as a psychiatrist. And a pandemic? What are you talking about?”

Had someone told me two years ago that I, as a psychiatrist, would be leading a public health response for a homelessness services agency during a global pandemic, I would have furrowed my brow: “What are you talking about?”

And here we are.

We’ve never had so many people—staff and patients—test positive for Covid at one time during the pandemic as we have in the past three days. Thankfully, most have had only mild symptoms and none, thus far, have needed hospital-level care.

The work we’re doing for Covid isn’t as intense or heartbreaking as the work my colleagues are doing in emergency departments and hospitals. Never before had I thought that a homelessness services agency could play a vital role in prevention and early intervention.

And here we are.

Throughout the pandemic, our team has framed our efforts as one way to keep people out of emergency departments and hospitals. These could be our humble contribution to our colleagues working in inpatient settings. We have been largely successful, though I worry that our luck is running out.

We continue to witness the indirect effects of the pandemic. Some have been lethal: Suicides and overdoses, whether intentional or not. Some are worrisome: More irritability and increasing intolerance for the challenges and annoyances of life, regardless of one’s station. I wince when I consider what might come next as we witness this surge of cases.

God have mercy on us all.

Categories
Consult-Liaison Education Medicine Nonfiction Systems

More Annotations on the Britney Spears Transcript.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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COVID-19 Education Medicine Seattle

Information about the Covid-19 Vaccines for a Non-Medical Audience.

For work, I created a presentation about the current Covid-19 vaccines for a non-medical audience. Maybe you will find it helpful, too. Here’s the agenda:

… where King County refers to the county in Washington State where Seattle is located. The presentation reviews the New England Journal of Medicine paper on the vaccine from Pfizer, as well as the data Moderna shared with the FDA. (Note that I made this slide deck near the end of December, so, if you are reading this in the distant future, data included may be different.)

I usually don’t include so much text in my slides. I made an exception here, as there are nearly a thousand people working at the agency and many may not be able to watch and hear me present this live. Enjoy.

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Consult-Liaison COVID-19 Homelessness Medicine Nonfiction Seattle Systems

“The Impact of Covid-19 on Homeless Services in Seattle.”

On Friday, I presented Grand Rounds to an agency in New York City. The title of my presentation was “The Impact of Covid-19 on Homeless Services in Seattle, Washington”. The audience was comprised mostly of psychiatrists who also work with people who are currently unhoused or have been homeless in the past.

In some ways, this presentation was easy to create: I simply described the agency I work for and walked the audience through the timeline of events:

While the Seattle-King County region was scrambling due to the first death from Covid-19, the first case of Covid-19 was diagnosed in New York City on March 1.

In other ways, this presentation is the only one I’ve made where I had to take breaks while making it because of anger, grief, and sadness.

The month of March was hectic for us and everyone else: We tossed routine policies out the window and scribbled new ones down. We shattered many of our old habits and hastily introduced new practices. Our collective workload increased significantly as we tried to be as flexible and responsive to the changes that were coming at us. We watched systems grind to a halt because systems can’t change that fast: We had to buy hand sanitizer from local distilleries and we donated N95 masks to hospitals. Systems that had long failed us suddenly had the harsh glow of media light on them: In all of Seattle, there were only five bathrooms with hand-washing sinks that were open 24/7. Congregate shelters, where over 200 people had no choice but to share one giant room and one bathroom, suddenly became unacceptable because the beds were not at least six feet apart.

And, yet, eight months later, not much changed. We haven’t had the opportunity to abandon restrictions; many of these new practices are now status quo because the situation hasn’t gotten better. I was honest with the audience: There was no resolution or hopeful conclusion at the end of my talk. Why was that? How could it be that, eight months later, things hadn’t actually changed much?

The audience said nothing. What is there to say? The lack of ownership and coordination at the federal level is the same now as it was in March/April. New York City has significantly more resources than Seattle, though those resources only go so far while SARS-CoV2 can cross state lines and national boundaries when no barriers are erected and no interventions happen. If people in a boat are not rowing in the same direction—or if people aren’t rowing at all—then the boat and everyone in it wastes a lot of time and energy.

I was surprised by the gifts of validation from the audience. Yes, we all work as psychiatrists and the last time most of us saw someone get intubated was when we were residents. However, we all recall doing consults on people in the ICU who were sick. Ostensibly, we were there to take care of the patient and maybe their family members. We also know, though, that an important (and often unspoken) part of psychiatric consults is to support the treating team.

We all have a sense of how terrible it is for the treating teams. These are the reasons why we desperately try to keep people healthy and out of hospitals. We know that our contributions are small—most people don’t live on the streets, in shelters, or in supportive housing; most people don’t have diagnoses of schizophrenia or severe substance use disorders—but we also know that our people are often maligned when they pass through the doors into traditional health care systems. We all have a sense of how terrible it is for our people. We also know that, due to the stress of living marginalized lives, our people often have more severe health conditions. They already have many risk factors that increase the likelihood of complications and death due to Covid-19. We’re trying to mitigate the stress of everyone involved.

It’s heartbreaking, terrible, and unfair.

To end the talk on a positive note, I mentioned several things I am grateful for:

  • The rainy season has arrived in Seattle and I get to sleep in a dry bed indoors.
  • I have confidence in where I am going to sleep tonight.
  • I have a job and can pay my bills.
  • I know I will eat (again!) today.
  • There now exists technology where I can speak to an audience of colleagues on the other side of the continent!

These both mean a lot and nothing at the same time.

In the meantime, we continue to do what we can while we wait.

Categories
Consult-Liaison Medicine Nonfiction Reflection Systems

Mental Health Awareness Month During a Pandemic.

It’s been Mental Health Awareness Month during a pandemic.

When we look back at this time, people will have different memories of their experiences: Some will remember changes in job duties and extra time for leisure. Others will remember intense pressure and stress as essential workers. Still others will remember the despair due to unemployment and financial worries. We all will remember how the COVID-19 pandemic disrupted our routines and affected our mental well-being: It impeded our freedom to go outside, abilities to pursue the activities we want to do, and usual opportunities to express ourselves.

Wearing a face covering may mask the expressions of displeasure and anxiety on our faces, but it does not diminish the discomfort and worry we feel within. As many in our community try to avoid illness, some will fall ill and and others will succumb to death. There are reasons to grieve.

Because discomfort and anxiety are internal experiences, our culture often frames these reactions as a personal problem—a disorder of one individual mind. However, this pandemic has had adverse effects on everyone. Many of us are feeling the same emotions. These are unsurprising reactions to an unexpected and (hopefully) once-in-a-lifetime situation.

We must avoid medicalizing these reactions. Individuals receive psychiatric diagnoses within specific contexts. Our reactions as a result of the the pandemic are collective experiences within the same context. It is unfair to argue that all people experiencing distress during this pandemic have psychiatric disorders. This argument also undermines opportunities for communities to support their own members who are suffering.

Not all distress reaches the threshold for a clinical diagnosis, especially during extraordinary times. While mental health professionals can help people who feel anxiety and sadness, that doesn’t mean that increasing the number of mental health professionals and their services is the primary solution during this pandemic. Most people feeling worry and anguish now will not need specialized services. Support from people from the same culture or context can and will help people tolerate and then grow from these emotional experiences. Relationships, stemming from faith traditions, hobbies, cultural groups, and friendships, are invaluable during these times of stress, loss, and grief. Providing education and resources to the community at large, such as through programs like Mental Health First Aid,[1. You can learn more about Mental Health First Aid here. I have no affiliation with them.] can help ensure that those in our community receive attention and emotional support. Communities can also provide support through other concrete means, such as financial donations, food assistance, and employment opportunities. Though individuals should remain six feet apart, the distance does not dilute the healing power of relationships.

To be clear, some individuals do experience levels of distress due to the pandemic that warrant professional mental health intervention and support. This does not mean that they have meaningless relationships or are “weak”. We often do not know the struggles people endure. Complications from the pandemic can overwhelm already strained internal and external resources.

We are living through an extraordinary time in history. We are all experiencing psychological stress, though perhaps at different frequencies and intensities. There is nothing routine about our external circumstances, so there is nothing routine about our internal experiences, either. The pandemic has demonstrated how interconnected we are. Let us focus not on individual distress, but focus instead on how we can all help each other during this difficult time. This will not only bolster the mental well-being of others, but will help our mental health, too.