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Medicine Policy Public health psychiatry Systems

Reflections on Some Health Care Systems.

Items related to systems of health care that I learned and thought about this week:

National Medical Association. I am embarrassed to confess that, nearly 20 years after graduating from medical school, I learned only this week about the National Medical Association. This came about while I was learning some of the history of the American Medical Association (AMA). In short, the National Medical Association was created because the AMA would not admit Black physicians into the organization. (I have never been a member of the AMA. My reasons have been squishy; I never truly believed that the AMA represented me or my interests. That hasn’t stopped the AMA from sending me invitations in the mail to join! It seems that over 80% of physicians are not AMA members, so I’m certainly not alone.)

Alexander Graham Bell and Eugenics. This Journal of the American Medical Association (emphasis mine) editorial from 1908 reports:

The subject of the production of better men and women was brought before the American Breeders’ Association by Professor Alexander Graham Bell, the inventor of the telephone, who for many years has been interested in certain social questions, especially those relating to the condition of the deaf and the result on the next generation of the consanguinity of parents as regards the production of deaf and blind children.

No one ever brought this up when we learned that he invented the telephone.

It appears that Bell’s interest in “breeding” was his observation, though the collection of some statistics, that parents who are related to each other seem more likely to bear children who are deaf. Bell made “an appeal for the collection of statistics by trained men who are interested and who have the opportunity to secure the definite detailed information” related to “the production of better children”. The unnamed author(s) of the editorial go on:

We are securing survivals to a much greater degree than before, and now it becomes a duty to secure, so far as it is possible, the origin of members of the race who will be worthy of survival. After all, the most important problem in evolution is not so much the survival of the fittest as the origin of the fittest.

Over 100 years have passed and this ugly question of “breeding” persists.

The Chinese Exclusion Act. I’ve commented on this Act before (here and here), but here’s an opportunity to pile on the AMA even more. In 1901, the Journal of the American Medical Association published a “minor comment” about “The Exclusion of the Chinese“, which you can view in its entirety in the link above.

Reading this made me think of vile rhetoric that has revived during this Covid-19 pandemic. Recall recent references to “disregard of sanitation” due to “[maintainence] to the fullest extent their oriental habits and traditions”. The Chinese, they just won’t do as we do.

“That this is a Christian country and we regard them as heathen, should not make us altruistic to our harm.”

Do we hear echoes from 1901 in the US’s current Covid test requirement for travelers from China?

Prescriptive Authority for Psychologists. There is a House bill in the Washington State Legislature that will give prescriptive authority to psychologists. Five US states currently allow psychologists to prescribe medications.

While it is easy to stumble into a debate about whether this should happen or not, I think this is a distraction. This debate is a manifestation of failure in public health policy.

Instead of trying to increase the number of people who can perform a highly specialized task, why not increase the availability of community supports and services so people don’t need highly specialized treatment?

Consider the decrease in anxiety and depression that would result if people were confident they could pay their rent? feed their families? take time off to care for their newborn? secure an education or training–whether college or vocational school–that supports stable employment?

Think of the decrease in stress and trauma if people had better options than to sell drugs or sex? if neighborhoods had more green spaces and less air and noise pollution? if they had adequate and essential protections as “essential” workers?

Medical Mistrust and Meeting People Where They Are At. This paper about medical mistrust, racism, and health prevention describes an elegant way to recruit study participants: “collection of data [occurred] primarily in barbershops, venues with documented recent success in reducing blood pressure in African-American men”. It is elegant because it is simple, effective, and successful.

When I read this, I recalled a suggestion my father had around the time the Covid-19 vaccines were released. He lives near several Asian grocers, many of which are more like bodegas than grocery stores.

“Why don’t they set up vaccination stations outside these grocery stores? Everyone needs to eat. Elderly people go to these stores all the time. Laborers get snacks and cigarettes. Make it easy for people.”

Sometimes (often?) the best and most effective health care happens outside of medical spaces.

Categories
COVID-19 Homelessness Nonfiction Observations Policy Public health psychiatry Seattle

Gifts of Our Lives.

Photo by Leeloo Thefirst

(I know it’s the holiday season and I promise I’m not actually a grinch, but here’s your warning: This is going to be kind of a bummer of a post.)

Some recent scenes for your consideration:

  • The sliding wooden gate did nothing to dampen the sounds of traffic on the boulevard. Inside the wooden gate was a parking lot that was now occupied by around 40 small sheds, each painted a different color. At one end was an open-air shared kitchen and a set of small bathrooms. It was snowing, the kind of wet, clumpy snow that doesn’t stick, but instead seeps immediately into clothes, hats, and sleeping bags. Though people in this “village” are still technically homeless, they were at least protected from this unusual Seattle weather. Within a few minutes of my arrival, a skinny kid, maybe eight or nine years old, wearing a sweater, shorts, and sandals, ambled outside alone to look up at the sky. Later, another skinny kid, maybe thirteen or fourteen, came out, his hands shoved into the pockets of his sweatpants and his eyes fixed on the ground. I wondered what their ACEs scores were and hoped that, as adults, they would escape and remain out of homelessness.
  • As I threaded my way through the city and the morning chill, I kept a mental tally: One man wearing a tank top and making grand gestures at the sky; another shirtless man pacing in tight circles; one woman wearing a soiled hoodie, with either black ink or a black substance smeared across the bottom half of her face, picking up trash from water pooled in the gutter; a man hobbling with a cane and screaming a melody; a man emerging from a collapsed tent to fold up a crinkled black tarp; a woman with bare legs and swaths of bright green caked on her eyelids who, in slurred speech, offered me a wristwatch dangling from her fingers.
  • “We have burned down the house of mental health in this city, and the people you see on the street are the survivors who staggered from the ashes,” writes Anthony Almojera, an N.Y.C. Paramedic [who has] Never Witnessed a Mental Health Crisis Like This One, who also comments that “there’s a serious post-pandemic mental health crisis.”

Maybe my expectations about the pandemic response were too high. A pandemic is an act of God; what could mankind possibly do that can deter the power of God?

And yet.

There were things we could have done to protect mental health during a pandemic. I am not the only one who was (and remains) worried about the psychological consequences of this pandemic in the years to come. There remains insufficient mental health policy or policy implementation, insufficient resources, and insufficient political will, among other implementation failures of public mental health.

I do believe that hope is a discipline. It’s hard to practice every day. But this is why I still question whether my expectations were too high. God spared us—you, dear reader, and me—during this pandemic. For what reason? What can and should we do with the gifts of our lives?

Categories
Blogosphere Policy Public health psychiatry Systems

Prevention and Early Intervention in Psychiatry.

Two shops on a street, one a cafe and the other selling vintage goods. The building is made of brick and it's sunny outside.
Photo by Suzy Hazelwood

The inimitable Dr. Ryan McCormick recently wrote a piece that summarized research findings that he, as a primary care physician, can apply in clinical practice. In the section describing outcomes related to antidepressant dose, he notes:

As an aside, it may be shocking to note that psychiatrists prescribe only 21% of the antidepressants in the U.S., with the other 79% of prescriptions usually coming from primary care providers!

(Similarly, primary care providers write about half the prescriptions for benzodiazepines.)

Much of the burden of psychiatric services falls to primary care and emergency medicine. Some data suggest that nearly 60% of US counties do not have a single psychiatrist. While primary care and emergency medicine physicians can and do provide psychiatric services, they can be put into positions where they are addressing psychological issues beyond their scope of expertise. I mean no disrespect in writing that. Just as it is a terrible idea for me, a psychiatrist, to manage complex diabetes, it is unideal for non-psychiatrists to manage complex psychiatric conditions.

Sometimes people end up developing complex psychiatric symptoms and conditions because they are unable to access support, care, and services earlier. As a result, larger numbers of people end up accessing services in urgent or emergent ways (e.g., emergency departments and criminal-legal systems). Local jurisdictions then receive increasing demands to build crisis response systems. For example, Seattle-King County recently announced a future ballot measure to build five mental health crisis centers in the region.

There will always be a role for crisis centers, as life is unpredictable and collisions of fate and bad luck can result in crises. However, if the crisis system has the most open doors and is the most robust part of the system, then this will only increase the number of people who will use that system.

We can pick any point in a theoretical journey through the crisis system, but let’s start with the crisis center. Let’s say that all five centers have been established and that these centers receive the most dedicated funding and attention. Maybe John Doe is able to access the crisis center directly, which is a boon to first responders and emergency departments—it’s one less person they need to provide care for (and they’re often are not the best suited to give support, anyway). Once John Doe is not as overwhelmed, what are the next steps?

If the crisis centers have received the most dedicated funding and resources (staffing, advertising, etc.), that probably means that other resources—like step-down units or outpatient clinics—will not have the same level of support. Thus, it might be weeks or maybe even a few months before John can get into a clinic.

John can do the best that he can to make it until that appointment, but what if something else happens and he need urgent care? His choices might be limited to an emergency department (which, no offense to my ED colleagues, are not therapeutic places to be) or to return to a crisis center. He might call a first responder, but that might entail an encounter with law enforcement (which is often not people’s first preference). Unless other resources are made available—unless there are other pathways he can take—he will continue riding the merry-go-round that is the crisis response system.

This is why it is essential to build and sustain prevention and early intervention system while also building crisis response structures. The tired phrase is “moving upstream”, but that is the most stable way to get people out of the crisis system.

I agree (to a point) with the New York Times’s editorial board: The Solution to America’s Mental Health Crisis Already Exists. This article provides an accurate history of how a vision of community-based care for some of the most psychiatrically ill and vulnerable people in our communities got degraded. Do I think it is the solution? Only when I feel particularly optimistic. Do I think it is a solution that could yield great rewards? Yes, though ideally this would be paired with other non-medical, community-driven prevention and early intervention efforts.

Prevention and early intervention systems don’t need to formally reside with medical or legal structures. In fact, it is better for the whole community if they don’t. (Let’s not kid ourselves: The vast majority of people don’t want to spend time in the health care system, particularly with psychiatrists. The health care system can do amazing things, but it is also rigid, expensive, and requires people to jump through a lot of hoops.)

Nathan Allebach recently created a TikTok video that describes the decline of “third places” (and I am relieved that he recognizes that car-dependent suburban sprawl isn’t the sole cause community erosion). I’m not saying that community erosion is the primary cause of psychiatric symptoms and distress. However, the presence of social bonds and community could not only alleviate symptoms, but could also prevent some psychological problems. What if interpersonal social networks were robust and included both more and different kinds of people and perspectives? What if fewer people felt lonely and “Good Neighbor Day” didn’t have to be a thing? (Full disclosure: I have a professional crush on Dr. Vivek Murthy.)

If it is true that at least some psychiatric conditions are “medicalized” sociological problems, then this is an arena where non-medical (though not necessarily political!) interventions could be invaluable. Fewer people would believe that their only option is to ask Dr. McCormick for antidepressant medication for anxiety and depression. Non-medical, community-based activities might be sufficient. Fewer people would need to go to emergency departments or crisis centers because resources and options in the community would be inviting and easily accessible. Maybe two crisis centers, instead of five, would suffice. And people would spend less time with (and money on) health care professionals and services, and more with people they want to spend time with… people in their chosen communities.

Categories
Policy Public health psychiatry Reading Systems

Is Mental Health Political?

Items neatly arranged on a desk, including a clipboard with a blank white sheet of paper and a magnet board with separate letters spelling "politics".
Photo by Tara Winstead

Here’s another piece in the New York Times’s series on mental health and society: Mental Health is Political. (Forgive the generous quoting and quotation marks that follow.) Dr. Carr says:

In medicine, examples of reification [the process by which the effects of a political arrangement of power and resources start to seem like objective, inevitable facts about the world] are so abundant that sociologists have a special term for it: “medicalization,” or the process by which something gets framed as primarily a medical problem. Medicalization shifts the terms in which we try to figure out what caused a problem, and what can be done to fix it. Often, it puts the focus on the individual as a biological body, at the expense of factoring in systemic and infrastructural conditions.

She goes on to say:

When it comes to mental health, the best treatment for the biological conditions underlying many symptoms might be ensuring that more people can live less stressful lives.

… after clarifying that she is

not arguing that mental illnesses are fake, or somehow nonbiological. Pointing out the medicalization of social and political problems does not mean denying that such problems produce real biological conditions; it means asking serious questions about what is causing those conditions.

The crux of her argument is this (emphasis mine):

This principle is what some health researchers mean by the idea that there are social determinants of health — that effective long-term solutions for many medicalized problems require nonmedical — this is to say, political — means.

I think I understand what she is arguing here: There are systems in our culture that contribute to mental distress and illnesses. I generally agree with this. If entry level jobs consistently paid wages that allowed people to rent apartments in cities where they work, that would reduce psychological pressure. The stress of long commutes, public transportation, and car and gasoline costs would disappear. People would have more time to enjoy healthful activities instead of commuting. If people are spending more on housing than they can afford, this leads to the tension of living paycheck to paycheck. Insecurities related to eviction and homelessness grow. None of this contributes to psychological wellness.

However, I also wonder how she defines “political” throughout this piece. Is all psychological distress really “political” in nature? For people who experience auditory hallucinations and delusions, is their psychological distress “political”? (Recall that there are people with a diagnosis of schizophrenia who are not indigent: They sustain employment, pay their rent on time, and lavish their pets with treats.)

Are all nonmedical interventions for mental illnesses—whether “medicalized” or not—“political” interventions? At various times and places, there has been alignment between the political beliefs of the community and those in political power. Did rates of mental distress and illnesses significantly decline? (I don’t know the answer to this; if you do, let me know.) If alcohol use disorders are mental illnesses, does this mean that Alcoholics Anonymous and other 12-step groups are “political” interventions? If people who have lost loved ones to suicide and convene as a group to express grief and support, is this a “political” act?

Should we still describe our psychological distress as “political” when life is inherently stressful? Is the act of commiserating with other medical professionals for support during the pandemic a political act? Maybe it is; maybe we must turn to each other because we recognize that health authorities apparently cannot and will not provide more support to us. But maybe it’s not; maybe this is a community of care we intentionally cultivated over time.

I found some validation for my reactions in this Gawker piece: Failure to Cope “Under Capitalism”. Clare Coffey describes

an application of “the personal is political” so expanded in scope that, for a certain kind of person, personal problems, anxieties, and dissatisfactions are illegible or illegitimate unless described as political problems.

She further notes that

[the] invocation [of capitalism] immediately establishes a phenomenon in the realm of the political, without any further work required.

… if only political problems are legitimate, only political solutions are admissible. This has the odd effect of filtering all attempts at self-integration through a political lens.

By describing problems (like capitalism) and solutions as political, perhaps this absolves us of the work we can (and sometimes need) to do. How can one person’s action have any meaningful impact on a political problem like capitalism? Aren’t systems, by definition, much larger than individual people? She then points out:

But in fact there is no one to adjudicate between you and capital, no one to say yes, that really is too much, let’s reassign this project. …

There is no political program that will release you from the necessity of doing more than you should have to or feel capable of doing, in politics as in every other part of life.

I appreciate her exhortation:

This is your life. You do not have time to wait for the revolution to begin living it. You will always be able to find someone to give you permission not to live it. But no one is coming along to live it for you.

To be clear, I am not at all suggesting that we can eradicate mental distress and illnesses by simply yanking on those bootstraps. The statement that “mental health is political”—to me, at least—removes any agency we have as individuals. Yes, political interventions and actions can improve population (mental) health. However, some political interventions will have little to no impact on individual psychological health. There are choices we all can make, on our own, that can help improve our own psychological wellbeing. Furthermore, we each can make choices everyday that can improve the psychological health of the people within our six-foot radius. Our actions don’t have to be political statements.

Given the work that I do, I don’t need much persuasion to believe that systems have many direct and indirect adverse effects on people’s health. It also seems unreasonable, though, that politics will always provide solutions for mental distress and illness.

Categories
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.