Medicine Policy Public health psychiatry

Recent Readings.

(Note: There are two purposes to this post: One, to get back into a routine of writing and posting. Two, I moved my website to a different host (those of you viewing the actual website will see that the design is different). Because it will never be perfect (because what is?), I am posting as a public test to fix what needs to be fixed.)

Here are some interesting articles I’ve read recently, some of which are prompts for future posts here:

NPR: Stressed out about climate change? 4 ways to tackle both the feelings and the issues. I am largely unfamiliar with the literature on psychiatric conditions and climate change, though have read a paper or two (not recently) about the association of increased violence among people with increases in temperatures. I must also confess that that my current faith in psychiatry to address this in a practical way is brittle: Organized psychiatry (in the United States, at least) seemed unenthusiastic about supporting population mental health during the pandemic. Despite the urgent mental health consequences of Covid-19, organized psychiatry in the US seemed instead enamored with the topic in the next bullet point.

Wired: Is the Psychedelic Therapy Bubble About to Burst? A new paper argues that excitement has veered into misinformation—and scientists should be the ones to set things straight. I find myself feeling annoyed with the mushrooming ecstasy related to psilocybin and LSD (see what I did there?), among others. There are a number of reasons for this; I will be the first to state that some of my reasons are not valid. Much of my irritation stems from the limited evidence (at this time) to support psychedelics for more severe conditions, the limited number of people who can actually access this intervention (who can afford this? who has eight hours to spend with two therapists?), and why We as a Society do not instead invest in population-level interventions so fewer people will develop trauma-, depression-, and anxiety-related conditions (e.g., ensuring children aren’t hungry; supporting literacy and education so people have skills for employment; etc.).

The Hill: Suffering from burnout, doctors are working drunk or high on the job: report. A new report found the health care industry has been too slow to address its mental health crisis among doctors and nurses and often treats mental health as secondary to physical health. “Over the last three months, 1 in 7 physicians admitted to consuming alcohol or controlled substances at work.” This data came from interviews from a mental health company, so there’s potentially a lot of bias in the results. I am sorry to say, though, that I wasn’t surprised to learn this. Some health care workers were drinking or using controlled substances at work before the pandemic.

n+1: Lab-Leak Theory and the “Asiatic” Form. What is missing is a motive. I did not find this to be an easy read, though it engaged me enough that I was able to get through it. In short, the author, Andrew Liu, argues that the appeal of Covid-19 coming from a lab leak is a reflection of historical (and ongoing?) exoticization of the Orient, as well as fears of China’s economic power.

New York Times: Yes, We Mean Literally Abolish the Police. and Truthout: I Stole to Feed My Family and Was Incarcerated. We Need Resources, Not Prisons. I am not an abolitionist, though there are days when I wish I could be successfully persuaded to become one. (This reflects what appears to be my declining idealism as I age.) To be clear, I do not think incarceration has been or is an effective solution for many (and maybe most?) behaviors and problems. This conclusion comes from my experience working in a jail and with people who are poor and marginalized. However, examples easily come to mind for how law enforcement and incarceration have had some value: Consider Jeffrey Epstein or Ted Bundy. I don’t know what the answer is, though I do not think either pole (e.g., police state or abolition) are useful or desired solutions. I am open to changing my mind. (Related: This Twitter thread on the role of child protective services.)

New Yorker: The Lottery. Shirley Jackson wrote this short story in 1948 and I only learned of it in 2022! If you’ve never heard of it before, please go read it: It has excellent structure, which helps drive the story to its haunting and disturbing conclusion.

Policy Public health psychiatry Systems

Writing Down Words.

It’s been five months since I’ve posted anything… and not because I had nothing to say. As Gloria Estefan and the Miami Sound Machine sang:

But the words get in the way
There’s so much I want to say
But it’s locked deep inside

… except it was Covid that was breaking my heart. I still feel like I have aphasia when people ask me what happened and how I am doing. At least now I am able to blurt out some emotion words (“I was angry, but it’s really because I was profoundly sad”).

In the meantime, work I did during my tenure as a medical director at King County got some press: Why King County mental health facilities decline 27% of referrals. (The only reason why I agreed to have my photo taken for the Seattle Times piece was to give my dad something to smile at.) Here’s what I learned from this experience:

Write stuff down and share it. I left my position at King County in 2019. I wrote a report on this data every year between 2015 and 2019. I sent it out to relevant organizations and officials, whether they welcomed it or not. The Seattle Times journalist somehow discovered the 2019 edition of this report earlier this year. I am grateful that she found it interesting enough to publish it in the local paper of record. If you think it’s important, write it down and share it. Someone will eventually find it useful. (I suppose this is an underlying tenet of those of us who still write in blogs.)

Sometimes it’s easier to talk about stuff once you’re outside of the organization. Government, at all levels, has its communication protocols. Depending on where you sit in the hierarchy and what your status is, you may not be permitted to talk to the press. Or you are counseled to adhere to specific talking points. (I recall sitting for an interview with a local weekly publication; I was only allowed to speak to the journalist if one of the county communication officers sat next to me.) For this, my speech was more free.

People want to learn. The photographer and I met at a public staircase. I said, “I probably shouldn’t smile, since this isn’t a joyful topic.” She had a general sense of the article and asked questions. By the end of our time together, she learned about psychiatric hospital data and I learned about the experiences of newspaper photographers.

Ezra Klein interviewed Dr. Thomas Insel, a former director of the National Institute of Mental Health, on his podcast (“The psychiatrist and public health expert Thomas Insel discusses how mental illness is a medical problem that requires social solutions.” Dr. Insel’s formulation here is catchy, though oversimplified.) I appreciated Ezra asking Dr. Insel to clarify and elaborate on some of his statements. Dr. Insel and I, though both psychiatrists, have had different professional experiences. As a result, I offered the following reactions to Ezra and his team:

There is an overlap between people with serious mental illnesses and poverty, which is where social solutions may be the most effective. People with serious mental illnesses (e.g., schizophrenia, bipolar disorder, etc.) are often at greater risk of poverty. For example, someone with a diagnosis of schizophrenia may be unable to sustain employment, accrue hospital bills that they cannot pay, and end up receiving more attention from law enforcement. Conversely, poverty can exacerbate serious mental illnesses. For example, adolescents may run away from home due to domestic violence or other dangers at home. If these teenagers do develop psychiatric symptoms, they often have limited support to seek and access services (health care or otherwise). Social solutions (e.g., housing, supported employment, etc.) may only work for individuals who experience both serious mental illness and poverty. Many of the interventions Dr. Insel listed–clubhouses, job training, supportive housing–are available only to those who have Medicaid insurance, which, as you know, requires low income.

Psychiatric treatments in the US, for better or worse, occur within an American/European frame. Dr. Insel extolled the virtues of medications and psychotherapy (and, to be clear, he’s not wrong—the current evidence base supports the use of both for many psychiatric conditions), except these interventions have Western European origins (hence his reference to Freud). Different ethnic cultures and American subcultures may be uncomfortable with or outright reject the American system of diagnoses and treatments. There is evidence that indicates that Black people are more likely be receive diagnoses of schizophrenia and antisocial personality disorder, which remain two of the most stigmatizing diagnoses in psychiatry. This isn’t limited to race only; women seem more likely to be diagnosed with anxiety and depression. (Is this a remnant of antiquated ideas related to wandering uteruses? or because women are more likely to seek medical help for their concerns?) The traditional health care system has expectations about how people will present and express their concerns; it also has expectations about how people will receive and accept care. From an intersectional perspective, this may contribute to why certain populations are less likely to seek and accept psychiatric services.

Policies and culture are intertwined. I appreciated Ezra’s commentary about the role (or lack thereof) of policy as it relates to isolation and serious mental illnesses. I agree that that policies can only go so far to help promote social support and connection. Perhaps Ezra and Dr. Insel were trying to discern how current US culture reflects a lonelier society, and how policies can or cannot influence US culture to help reverse this? Policies come out of the current culture, but policies can also impact culture (e.g., women’s suffrage, civil rights, abortion bans, etc.).

Though it’s hard to prove the success of prevention, that may be the best way to address all three issues above. Because most of my work has been in the “deep end” of the system, I have become an ardent supporter of prevention and early intervention. (At the risk of sounding really self-righteous, I’d love to work myself out of a job!) So many people I’ve had the privilege of caring for have experienced terrible physical, mental, and sexual trauma as children and adolescents. What would it be like if people weren’t molested or assaulted when they were kids? What would it be like if pregnant people didn’t experience violence from their partners? What would happen if youth who identify as LGBTQ+ experienced acceptance and support from their families? What if emotional self-regulation skills were part of prenatal care and school curricula? These prevention efforts can be folded into policy, which can influence culture. Reducing (minimizing? eliminating?) poverty through policy could improve outcomes not only for mental health, but for physical health. (The Spirit Level by Wilkinson and Pickett provide some compelling data about this.) Ensuring that psychiatric interventions and treatments from non-American/European frames are funded and evaluated for efficacy not only increases treatment options, but these non-Western treatments may also appeal to different populations.

Funding for the mental health and substance use disorder systems is complicated; it took me years as a medical director to understand how it works at the county level. Funding systems should follow the clinical delivery of services, but, unfortunately, the delivery of psychiatric services (as with the rest of health care) is based on funding systems. This makes implementing services, accessing care, and improving outcomes needlessly challenging for actual human beings. While the 988 line is an encouraging development, I worry that, if the crisis system is the most robust part of the psychiatric care system, then crisis care will be the only place where one can get quality care. And no one should have to experience one of the worst days in their life to receive good care.

I can’t help but observe how my reactions above can also apply to how the US has responded (or not) to the Covid pandemic. I continue to grasp at words.

COVID-19 Nonfiction Policy Public health psychiatry Reading

Public Mental Health Implementation Failure.

Throughout the pandemic, I have routinely reviewed the major psychiatric journals in the United States, hoping for commentary about and guidance related to the prevention or minimization of psychiatric conditions due to the Covid-19 pandemic. Surely there are practices or protocols we could implement to prevent bad outcomes that we knew would happen! While the work we do with individuals might have some potential benefit, the scale of the pandemic meant that population-level interventions would have better effects for a greater number of people. From my point of view, if my finite time and energy could help more than the sole person in front of me, that would be better for all involved.

Three thousand years ago, back in December 2020, I commented that “collective problems require collective solutions; expertise must be decentralized and shared” while reflecting on the need to Protect Mental Health During a Pandemic. Now that three thousand years have passed, it seems that anyone at the federal level who tried to implement the Pan American Health Organization or World Health Organization recommendations from the flu or ebola epidemics was foiled. I lamented then that

We’ve already witnessed psychological stumbling across the population; none of us want to see ourselves, our neighbors, our communities, and those beyond beyond fall further.

We’ve graduated to chronic psychological lurching, floundering, and tottering. Most of the psychiatry journal articles have only described consequences from the current pandemic: who was more likely to get Covid-19? how did it affect the use of substances? how was the pandemic affecting the workforce?

Where were the articles with broad vision, that take the perspective of public health psychiatry?

The Lancet Psychiatry recently published an article that I found refreshing: Public mental health: required actions to address implementation failure in the context of COVID-19:

  1. It acknowledges how the mental health system—one of many—has failed during the pandemic (people may have opinions about whether it was succeeding prior to the pandemic);
  2. It lists specific failures and how to fix these problems (and there are a lot of problems to fix);
  3. It reinforced the need to direct attention and resources to all stages of the lifespan and the various roles, from individuals to national governments, each could play to prevent future failure.

The authors rightly comment

This failure of [public mental health] implementation results in population-scale preventable suffering of individuals and their families, a broad range of impacts…, and large economic costs. The failure also represents a breach of values and the right to health.

Panel 5 lays out how the implementation failures of public mental health:

  1. Insufficient public mental health knowledge
  2. Insufficient mental health policy or policy implementation
  3. Insufficient resources
  4. Insufficient political will
  5. Political nature of some [public mental health] activities
  6. Insufficient appreciation of cultural differences
  7. Causes of mental disorder treatment gap

Oof. It’s a valid list and, indeed, some of the responsibility falls upon mental health and substance use disorder clinicians ourselves. (Different posts for different days.) It’s also striking that, despite the United States being a high income country, we suffer from the same problems listed above that apply to low income countries. (We, however, continue to learn the many ways how the US was and is never different from “those” low income countries.)

As I noted a few weeks ago, “We continue to focus on the viral pandemic; the psychological pandemic has already arrived.” Because of our missteps, the psychological pandemic will also outlast the viral pandemic. The authors note that

The COVID-19 pandemic has widened the implementation gap but has also increased mental health awareness and highlighted the need for a [public mental health] approach.

Now that we are minding the gap, I hope that we can indeed close it.

Homelessness Nonfiction Policy Public health psychiatry Seattle

Shelter “Isolation” and “Quarantine”.

Though the room layout follows pandemic guidance, it still feels crowded.

Dozens of beds are placed six feet apart. In a homeless shelter, each twin mattress is multipurpose furniture: Yes, it is a bed where people sleep. It is also a table upon which they eat simple meals stuffed into brown paper bags. It is a living space of 38 by 75 inches that offers no privacy and no isolation.

Say someone living in the shelter falls ill with Covid. Should this person be allowed to stay in the shelter, but risk infecting others? Or should the shelter ask this person to leave and recover in the chill and darkness of January?

Seattle-King County has been a leader in implementing isolation and quarantine (I&Q) sites for people who don’t have their own place to live. These are hotels that allow people who were exposed to or infected with Covid-19 to rest and recover away from others. The hotels have specialty staff who provide physical and behavioral health care. Once recovered, people can return to shelter or similar congregate settings. It is difficult to prove the success of prevention, though removing people from congregate settings likely reduced infections. This, in turn, reduced hospitalizations and deaths.

Last winter, there were four I&Q sites. This winter, there are only two.

This reduction isn’t for lack of need. As with the general population, the omicron variant has caused a crush of infections in shelters. The I&Q sites, like most health care agencies, cannot hire enough people to provide services. This reduction in I&Q sites is entirely due to an insufficient number of staff.

Because fewer health care workers now work at the I&Q sites, the county has had to enact more exclusion criteria to preserve this service. Providing support for people with multiple health conditions requires professionals with expertise and experience; physical space and supplies are not the only considerations.

This means that people living in shelters who are ill with Covid will be denied admission to I&Q sites.

That means that people who are sick with Covid may only have bad options to choose from. If they’re lucky, they may be able to stay in a shelter. However, their living space of 38 by 75 inches has no walls. Sights, sounds, and air are all shared.

The average age of someone experiencing homelessness for the first time is now 50 years old. People who live in shelters, cars, or outside are more likely to have chronic health conditions like high blood pressure, diabetes, depression, and anxiety. These conditions are risk factors can result in more severe cases of Covid illness. These same factors also increase the risk of disease and death if people are sent outside.

With the attrition of health care and essential workers, the burden of illness and disease will fall upon the most vulnerable people in our communities.

This also means that staff who are still able and willing to work at the shelters–all essential workers–are at increased risk. Most shelters do not have access to medical expertise or consultation. If there is nowhere to send people who are ill with Covid, shelter workers will have to decide what to do if someone in the shelter gets sick. We cannot expect all shelter staff to have the skills, knowledge, and desire to provide isolation and quarantine support. If shelter workers send someone out, that will only put more burden on the safety net of first responders and emergency departments. This safety net is already fraying and breaking after two years of crisis.

Systems cannot rely on single individuals, though this has been happening more and more as the pandemic has dragged on. As various systems falter and crumble, we see the demoralization and exhaustion of all who provide essential services. More distressing are the detrimental effects these system failures have on vulnerable people we want to serve well, but cannot.

This is unfair to all involved. Inside and outside of the crowded room of the shelter, it is with horror that we realize that all of our options are bad.

COVID-19 Nonfiction Policy Public health psychiatry Systems

Pandemic of Demoralization.

I haven’t posted much recently because I don’t want to be a bummer. There’s enough of that in the world right now: disasters on a global scale and quiet tragedies just down the block.

I worry about the health care workforce. While it is indeed a privilege to go to school to learn about illness and health and then apply those skills to people who somehow trust us, this pandemic has squeezed and stretched us in ways none of us could anticipate. Not only do we see people who get sick with Covid-19, but we also see all the people who get sick from everything else because of the system pressures and failures due to Covid-19.

I see the fatigue on my colleagues’ faces; I see their struggles in trying to provide the best care they can when they themselves are not thinking or feeling their best—now going on for over a year.

We all remain focused on the Covid pandemic, though the demoralization[1. “Demoralization is a feeling state of dejection, hopelessness, and a sense of personal “incompetence” that may be tied to a loss of or threat to one’s own goals or values.”] pandemic has already descended upon us. While the pandemic has fostered more conversations about mental distress and illness, no robust system has emerged to take care of those who take care of others.[2. It is not only health care workers who would benefit from care from people and systems.] (How could we expect a robust system to emerge when the system—if there was one—was fragile prior to this pandemic?) This distress manifests in dreams and dissociation, prickliness and physical pain, withdrawal and wretchedness.

I never formulated my specific work as “public health psychiatry”, though, in the months before the pandemic, this idea crystalized in my mind. Most of my career has focused on the “deep end” of the system: homelessness, crisis, jails, and poverty. While people can and do get better, the challenges are great when one is reacting to, rather than navigating through, these barriers and systems.

So much of what I do is tertiary prevention (“managing disease post diagnosis to slow or stop disease progression“). Fewer people would need “deep end” services if there were more agile and reliable primary and secondary prevention systems. How much healthier would people be if they were never sexually assaulted as children? if parents were able to feed themselves and their children with confidence? if everyone had a stable and safe place to live?

For our health care workforce now, it is too late to prevent demoralization and exhaustion. It seems that the best that we can do is prevent more harm from happening. Tertiary prevention is still prevention, though this is hard to reconcile with the realities of our daily work: Will tertiary prevention buoy us enough so that we can give good enough care to our patients?