Category: Public health psychiatry

Categories
Homelessness Policy Public health psychiatry

The Word “Mental” in Project 2025. (vi + vii)

The sixth instance of the word “mental” is on page 509 in the section about “First-Day and First-Year Administrative Reforms” for The Department of Housing and Urban Development (emphasis mine):

The Office of the Secretary should execute regulatory and subregulatory guidance actions, across HUD programs and applicable to all relevant stakeholders, that would restrict program eligibility when admission would threaten the protection of the life and health of individuals and fail to encourage upward mobility and economic advancement through household self-sufficiency. Where admissible in regulatory action, HUD should implement reforms reducing the implicit anti-marriage bias in housing assistance programs, strengthen work and work-readiness requirements, implement maximum term limits for residents in PBRA and TBRA programs, and end Housing First policies so that the department prioritizes mental health and substance abuse issues before jumping to permanent interventions in homelessness. Notwithstanding administrative reforms, Congress should enact legislation that protects life and eliminates provisions in federal housing and welfare benefits policies that discourage work, marriage, and meaningful paths to upward economic mobility.

The seventh instance of the work “mental” is on page 516 as a footnote to the paragraph above (emphasis again mine):

The U.S. Interagency Council on Homelessness (USICH) was established in the 1990s, and numerous Administrations have devoted enormous resources to the Housing First model, experimenting with various ways to provide federally financed rapid rehousing and permanent housing opportunities. Housing First is a far-left idea premised on the belief that homelessness is primarily circumstantial rather than behavioral. The Housing First answer to homelessness is to give someone a house instead of attempting to understand the underlying causes of homelessness. Federal intervention centered on Housing First has failed to acknowledge that resolving the issue of homelessness is often a matter of resolving mental health and substance abuse challenges. Instead of the permanent supportive housing proffered by Housing First, a conservative Administration should shift to transitional housing with a focus on addressing the underlying issues that cause homelessness in the first place.

    Long-time readers will recognize that this falls right into my professional bailiwick…

    (cracks knuckles)

    … but I won’t spend too much time on the data because there are excellent summaries elsewhere. For example, the Office of Policy Development and Research published Housing First: A Review of the Evidence. There they describe the stance the federal government took in the 1990s, summarized as “treatment first”:

    housing was available only to individuals experiencing homelessness who were willing to work for it.

    This is exactly what the authors of Project 2025 want. If they know this history, they know that this “treatment first” model did not reduce homelessness, but an alternate model called “housing first” did, and for various populations:

    Overwhelming evidence from several rigorous studies indicates that Housing First programs increase housing stability and decrease rates of homelessness. The best available evidence indicates that Housing First programs successfully house families and individuals with intersecting vulnerabilities, such as veterans, individuals experiencing substance use or mental health issues, survivors of domestic violence, and individuals with chronic medical conditions such as HIV/AIDS. 

    While the authors of Project 2025 argue that “mental health and substance abuse challenges” are the “underlying issues that cause homelessness in the first place”, they again are ignoring data that illuminates the actual underlying issue (emphasis again mine):

    Much of the research looks at the variation in homelessness among geographies and finds that housing costs explain far more of the difference in rates of homelessness than variables such as substance use disorder, mental health, weather, the strength of the social safety net, poverty, or economic conditions.

    Is it true that there are some people who are homeless because of their “mental health and substance abuse challenges”? Yes. However, their common denominator is not having enough money. There are people with “mental health and substance abuse challenges” who are not homeless and that’s because they have enough money, or someone else has enough money, to pay their rent. (Think of the depressed ladies who buy cases of wine from Costco and return to their suburban homes to drink 20 bottles of wine a week….)

    So that’s the data. But, as a psychiatrist who works with people who are or were homeless, let me share some some “n of 1” perspectives about the work.

    Importantly, most people who are homeless don’t need the services of a psychiatrist. Could they use mental health support? Sure: When you don’t know where you’re going to sleep tonight, anxiety is a natural reaction. If you find a place to sleep, but there isn’t a door you can lock (or a door, period), you probably won’t sleep well. Without routine access to a bathroom or running water, you can’t keep yourself as clean as you would like, so you start feeling self-conscious about it. It’s hard to perform well at work if you aren’t sleeping well, you don’t feel your best, and you don’t have a place to call home. You know what solves these psychological problems better and faster than a psychiatrist? Housing.

    A psychiatrist can help people with significant psychiatric conditions (like schizophrenia) who are homeless. Among the reasons some people have shared with me about why they will not move indoors:

    • The aliens will assassinate me if I move inside.
    • I want an apartment, but God tells me that I don’t deserve to be indoors.
    • If I move in, they will turn on the parametric speakers to make me insane.

    Most of these people don’t have jobs because their symptoms get in the way of their ability to show up on time, work with customers, etc. Because many of them have had terrible experiences with the traditional health care system, some are reluctant to talk with me. But, with the essential help of my non-medical colleagues, many will. Some people, with time and relationship-building, will agree to try medication to treat their symptoms. (Yes, this really happens.)

    When you don’t have a stable place to live with a door to lock and easy access to cabinets and calendars, it’s hard to take medication as prescribed. Pills get lost. Other people might pilfer them. Someone might run off with your bag. Plus, if medications make you sleepy, you might only take them when you know you can sleep safely. You know what makes it easier to take medication on a regular basis and manage side effects like sedation? Housing.

    Maybe you’ve heard about long-acting injectable medications. Instead of having to take a pill every day, you can get a shot once a month. This sounds like an elegant solution, right? Some people are cool with shots, but a lot of people aren’t. (Would you want to get a shot every month instead of taking pills?) But let’s say our hypothetical patient who doesn’t have a place to live is willing to get a shot every month. (This really happens, too, but not as often.) The challenge here is finding the person every month to administer the shot. Maybe they will come to a clinic or other meeting spot, but their symptoms can make tracking time (and appointments) a challenge. I can go out and try to find them, but if they move around (because of their symptoms, privacy, safety, etc.), there is no guarantee that I will. You know what helps people receive their medications like monthly shots on a routine schedule? Housing.

    But let’s go to an extreme. Let’s say that I’m working with someone who is homeless whose psychiatric symptoms are severe and dangerous. Maybe they have stopped eating because they are certain that they don’t have internal organs. Or how about this: A man is chasing children with a lead pipe because he believes that the kids are government agents trying to kill him. Here I exercise my coercive power: I go through the steps to hospitalize both people against their wills for psychiatric reasons.

    So now they’re not on the streets, they are in a hospital somewhere. Time passes, treatment works, and they no longer need to be in the hospital. So where are they supposed to go upon discharge? They didn’t have a place to live before the hospitalization. In this Project 2025 universe, they don’t deserve housing because they’re not working, so back out onto the streets they go. And the cycle begins all over again.

    Let me also tell you that most people under my care want to work. Because people who are homeless live in the same culture as those of us who have housing, we are all indoctrinated in the idea that there is value in work, and your value as a person involves work. The jobs they often want are often completely reasonable. The person who thinks the aliens will assassinate her? She wants to work as a bookkeeper again. The person who fears the parametric speakers? He’s open to working in the print shop. The person who hears God telling him that he can’t move indoors? He’d like to be a barber. But when you don’t have an address to put on your job application, or you don’t have the money to apply for classes or a business license, how can you make your employment dreams a reality?

    If the goal is to reduce the number of people who are homeless, then accept the research data and make housing more affordable for all. If the goal is to reduce the number of psychiatrically ill people who are homeless, then ensure that they have stable places to live so they can meaningfully participate in treatment.

    But if the goal is to coerce people, with the threat of homelessness as the cudgel, to live according to the values of the Project 2025 authors, then just be up front about it. Just make sure you follow that line of reasoning to its logical conclusion: Put it in writing that you believe some people deserve to be homeless — and thus deserve to die.

    Categories
    Medicine Policy Public health psychiatry

    The Word “Mental” in Project 2025. (iv)

    (I am skipping over the third instance of the word “mental” in Project 2025 for now. There are two reasons for this: First, the quote is “mental or psychological issues”, which is part of a long list of categories of information. Second, the relevant paragraph describes the Family Educational Rights and Privacy Act (FERPA) and Protection of Pupil Rights Amendment (PPRA). I am not familiar enough with either regulation. To understand what the author is trying to say, I will need to read more. If you know more about this and are willing to explain it to me, feel free to let me know.)

    The fourth instance of the word “mental” is on page 461 under the section of National Institutes of Health:

    Finally, HHS [Department of Health and Human Services] should create and promote a research agenda that supports prolife [sic] policies and explores the harms, both mental and physical, that abortion has wrought on women and girls.

    The construction of this sentence is curious. A generous interpretation is that the author has limited experience with research and is unfamiliar with the order of operations. Another possibility is that the author is intentionally dressing up an opinion in the lab coat and safety goggles of unbiased science.

    Scientific research begins with questions. Studies seek to answer these questions. Once there are good enough answers, officials can then craft policies that are informed by these answers. We all understand that more questions will come up, which leads to more studies, which leads to more answers, some of which will challenge what we once knew. We learn and adapt accordingly.

    The more logical framing of this short paragraph would be:

    • Does abortion cause mental and physical harms for women and girls? (That question can be answered through research.)
    • If the answer is yes, then develop pro-life, anti-abortion policies.

    The thing is, research already exists that answers the question, “Does abortion cause mental and physical harms for women and girls?”

    Please meet the Turnaway Study:

    The Turnaway Study is [Advancing New Standards in Reproductive Health]’s prospective longitudinal study examining the effects of unwanted pregnancy on women’s lives. The major aim of the study is to describe the mental health, physical health, and socioeconomic consequences of receiving an abortion compared to carrying an unwanted pregnancy to term.

    Note that the Turnaway Study actually asks two questions:

    1. Does abortion for an unwanted pregnancy cause mental and physical harms for women and girls?
    2. Does carrying an unwanted pregnancy to term cause mental and physical harms for women and girls?

    (Another note: The Turnaway Study included females ages 15 and older, so does not include all girls who could get pregnant.)

    The authors of Project 2025 do not include the second question in their call for research. Is it that they do not care? Or that the answers would not change their minds?

    The Turnaway Study is clear in its results:

    The main finding of The Turnaway Study is that receiving an abortion does not harm the health and wellbeing of women, but in fact, being denied an abortion results in worse financial, health and family outcomes.

    When specifically examining mental harms, the Turnaway Study found “women who have an abortion are not more likely than those denied the procedure to have depression, anxiety, or suicidal ideation.” There was also no evidence that women were more likely to use more tobacco, alcohol, or drugs after an abortion.

    Now, let’s be clear: The results of the Turnaway Study do NOT show that women who have an abortion never experience symptoms of anxiety, depression, PTSD, or suicidal ideation. (I assume this is what the Project 2025 authors mean when they write “mental harms”.) The study shows that the rates of these conditions are about the same whether women with unwanted pregnancies receive abortions or not.

    That’s the thing with research. Scientific studies examine groups of people, not individuals. While most women who have an abortion (or not) won’t experience anxiety or depression, a small percentage will. If you’re one of the women who does, that sucks. But just because one woman has an unwanted psychological outcome doesn’t mean that all women will. Multiple factors, including chance, contribute to the risk.

    The Royal We make choices all the time that involve significant risk, though we assume that we will be fine because the odds are in our favor. Let’s use the following question to test our assumptions of safety: Are you more likely to die while being in a moving car, or from accidentally falling down?

    The numbers are close, but you’re more likely to die from unintentionally falling (14/100K) than from being in a moving car (13.4/100K)! You’re also far more likely to die while in a car or from falling down than from a homicide (7.5/100K).

    However, despite this data, no one has suggested a policy platform on the federal level to prevent falls. (Similarly, no one is advocating the outlawing of cars.)

    If the authors of Project 2025 were open to editorial feedback, I would suggest that they omit words to punctuate their point:

    Finally, HHS [Department of Health and Human Services] should create and promote an agenda that supports prolife policies.

    There’s no point in doing research if the results won’t change what you do. Just say what you mean.

    Categories
    Policy Public health psychiatry Reading

    The Word “Mental” in Project 2025. (ii)

    The second instance of the word “mental” in Project 2025 is on page 6, just a few paragraphs after its first appearance in the foreword:

    This resolve [“Every threat to family stability must be confronted”] should color each of our policies. Consider our approach to Big Tech. The worst of these companies prey on children, like drug dealers, to get them addicted to their mobile apps. Many Silicon Valley executives famously don’t let their own kids have smart phones. They nevertheless make billions of dollars addicting other people’s children to theirs. TikTok, Instagram, Facebook, Twitter, and other social media platforms are specifically designed to create the digital dependencies that fuel mental illness and anxiety, to fray children’s bonds with their parents and siblings. Federal policy cannot allow this industrial-scale child abuse to continue.

    This 100-word paragraph features inflammatory language sure to capture a caring parent’s eye: drug dealers! addicting! child abuse! Let’s take a closer look:

    Are social media companies preying on children like drug dealers? I don’t know the intentions of leadership at social media companies, but there is evidence that these companies make mega amounts of money from the attention of youth. One paper revealed that, in 2022, “advertising revenue from youth users ages 0–17 years [was] nearly $11 billion”.

    Billion with a B! Let’s name names. According to the same paper:

    The greatest advertising revenue profits derived children [sic] ages 0–12 years old was from YouTube ($959.1 million), followed by Instagram ($801.1 million) and Facebook ($137.2 million). Among youth ages 13–17 years old, the greatest estimated advertising revenue was generated on Instagram ($4 billion), TikTok ($2 billion), and YouTube ($1.2 billion).

    (It’s true: Only old people use Facebook.)

    How do these numbers compare to other businesses?

    EntityRevenue (one year)
    Los Angeles Dodgers$549 million
    Taylor Swift$1.04 billion
    Cannabis tax revenue$3 billion

    Instagram made more money than Taylor Swift!

    Is it true that “many Silicon Valley executives famously don’t let their own kids have smart phones”? It looks like the answer is yes, or at least they restrict their kids’ access to media.

    Do social media platforms “create the digital dependencies that fuel mental illness and anxiety”? In short, the answer is yes, but not for every child and adolescent.

    The excellent Surgeon General Vivek Murthy issued an advisory about the effects of social media on youth mental health:

    Usage of social media can become harmful depending on the amount of time children spend on the platforms, the type of content they consume or are otherwise exposed to, and the degree to which it disrupts activities that are essential for health like sleep and physical activity. Importantly, different children are affected by social media in different ways, including based on cultural, historical, and socio-economic factors.

    The American Academy of Pediatrics (AAP) has a Center of Excellence on Social Media and Youth Mental Health that includes a policy statement on the risks and benefits of social media use and how media can affect the development of young minds.

    The American Psychological Association has shared information about relationships between the amount of time youth spend on social media and mental health outcomes (more time spent associated with worse outcomes), why young brains are especially vulnerable to social media, and called out social media companies to improve the safety of their products.

    Does social media fray children’s bonds with their parents and siblings? The framing of their argument suggests that the fraying of bonds is entirely the fault of children using social media. Kids don’t have the money to buy phones and computers themselves. Humans learn through observing.

    AAP correctly states:

    Parents’ background television use distracts from parent–child interactions and child play. Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits, reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

    This research paper about problematic media use in early childhood points out that “parent’s PMU [problematic media use] remained the strongest correlate of concurrent child PMU” and “parental warmth and responsiveness might be protective of the development of PMU among young children”.

    In sum, the authors of Project 2025 have some legitimate and evidence-based concerns about the adverse effects of social media on kids.

    So why do the authors of Project 2025, who have voiced support of the incoming President, seem to have no issue with his own social media platform (Truth Social)?

    And why, after vilifying Silicon Valley executives, is there no outcry about Elon Musk, now an owner of a (financially failing) social media company, having a position in the federal government? (Also, is it efficient to have two leaders of the Department of Government Efficiency?)

    And if the authors of Project 2025 want to change federal policy to prevent “industrial-scale child abuse”, then surely they want to prevent deaths of children. For [the] third straight year, firearms killed more children and teens, ages 1 to 17, than any other cause including car crashes and cancer. There are solutions to prevent guns from killing kids. Strange that there are absolutely no firearm policies in Project 2025!

    Categories
    Homelessness Policy Public health psychiatry Systems

    Homelessness and the Supreme Court.

    Tomorrow (April 22) the United States Supreme Court will hear oral arguments in the case City of Grants Pass, Oregon, v. Gloria Johnson. This article, 5 things to know about the Grants Pass homelessness case before the US Supreme Court, summarizes the issue well: “The repercussions could have national implications for how cities can regulate homelessness.” In short, if the Supreme Court sides with the City of Grants Pass, it could essentially be a crime to be homeless. (Note: “Homelessness” here refers strictly to street homelessness. The federal definition includes other populations that are not as visible, such as people living in shelters, people about to be evicted, etc.)

    This brings to mind other information:

    California Statewide Study of People Experiencing Homelessness. This came out in June of 2023. It’s one of the few recent surveys that examines mental health conditions and substance use among people experiencing homelessness. Over 3,000 people in various parts of California answered surveys and over 300 people participated in detailed interviews. They didn’t administer technical interviews to determine whether people met diagnostic criteria for psychiatric conditions. They instead asked people if they had ever experienced certain symptoms (e.g., hallucinations, anxiety, depression) or engaged in certain behaviors (e.g., used any substance three or more times a week) in the past or at the time of the interview. More than half of the people who responded said that they either had a mental health condition in the past or were experiencing one now. More than half reported that they had used substances in the past; about one-third reported that they were currently using any substance at least three times a week. (Note that “substance” here does not include alcohol or tobacco.)

    JAMA Psychiatry: Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness. I have yet to read this paper. It’s a review and analysis of past research related to this topic (a research study of past research studies, if you will). It looks like they looked at specific diagnoses, with a call out of 44% of people experiencing homelessness experiencing any substance use disorder. Other highlights included in the abstract include prevalence rates for antisocial personality disorder (26%) (one of my most popular posts—from 2013!—is about this condition, for whatever reason… and I’ve been wondering about this one again), major depression (19%), schizophrenia (7%), and bipolar disorder (8%).

    Open drug scenes: responses of five European cities. This paper is from 2014, though it holds lessons that we in the US can and should learn from. The information within disappoints everyone, which means it is probably a reasonable map to use.

    Open drug scenes are gatherings of drug users who publicly consume and deal drugs.

    To be clear, as evidenced by data shared above and from anecdotes from those of us who do this work, not everyone who is homeless uses drugs. Not everyone who uses drugs is homeless, either. Much of the current discourse about homelessness is related to drug use, though, which is why I bring up this paper.

    The five cities described in the paper vary in size (Zurich, Switzerland, at around 415,000 people to Lisbon, Portugal, at 2.7 million people), though they each use similar strategies to reduce and eliminate open drug scenes:

    • drug dependence is a health problem
    • drug use behavior is a public nuisance problem
    • need for low threshold health services, outreach social work, and effective policing
    • appropriate combinations of harm reduction and restrictive measures

    Law enforcement is needed to address the public nuisance problem. Robust health and social services that include harm reduction are needed to address the health problem. (At least two of the cities legalized heroin so people can use drugs safely in monitored settings, with hopes that they will one day use less and perhaps stop. Recall that this paper came out before the destructive wave of fentanyl overcame us.) Most cities have yet to find the “appropriate combinations” to reduce open drug scenes. (Just to reiterate, these strategies did not eliminate homelessness, only open drug scenes.)

    Textbook Talk: Dr. Van Yu on Housing First and the Role of Psychiatry in Supported Housing. One significant way to eliminate homelessness is to ensure that people have places to live. Lemme tell ya: It is hard to effectively treat someone’s mental health or substance use disorder if they don’t have a stable place to live. If the person can’t or won’t come to you, that means you have to go to them. If you can’t find them (because they don’t have a place to live so they move around a lot), it’s hard to make a connection to help them. Even if they want to participate in treatment, it’s challenging to Do All the Things when you don’t know where you are going to sleep. Can you imagine what you’d do or how you’d feel if you didn’t know where you were going to sleep tonight? Seeing a health care professional likely won’t be your priority. Working in a Housing First or other public setting also changes the way you think about health care: Your interventions don’t just affect one person; they affect a whole community. Conversely, the community influences your interventions as a health care professional. We naturally become systems thinkers. (Full disclosure: Dr. Yu was once my boss. I learned and continue to learn a lot from him.)

    I will follow the City of Grants Pass, Oregon, v. Gloria Johnson case with interest. The problem of homelessness is complex because people experiencing homelessness each have distinct challenges. They are not a monolith. I believe that there are government officials who are sympathetic to their circumstances. I still wonder, though, what problem are they trying to solve? Is it that they don’t want people to live outside? Or that they don’t want to see people living outside?

    Categories
    Education Observations Public health psychiatry

    What is Mental Health? (03)

    Let’s take a look at the last figure from the paper What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey. The authors call this the Transdomain Model of Health:

    I like this model. (Do note, though, that the map is not the territory.) It reminds us of the interdependencies between and within ourselves. If our community isn’t doing well, that will affect our individual mental health. To intentionally use a trivial example (because there are WAY too many heavy things happening these days), consider a city’s baseball team. A not-so-fictional team called the Tridents has had some embarrassing games; hits are uncommon, fielding errors abound, and pitchers are giving up a lot of runs. Grumpy viewers write corrosive comments about the Tridents in the city’s newspaper. Suckers like me read the comments and feel a disjointed sense of “us”. Maybe some of these grumpy viewers are in foul moods for other reasons and they direct their ire at the Tridents because that’s easier to talk about than their alcohol or gambling problems. They would go to Cell Phone Carrier Stadium to grumble at the Tridents directly, but they are dealing with illnesses that limit their abilities to navigate social spaces. Most of us don’t feel psychologically fine when we are physically unwell.

    Contrast this Transdomain Model of Health with this recent Psychiatric News article, Lifestyle Psychiatry Emphasizes Behaviors Supporting Mental Health.

    The authors define “lifestyle psychiatry” as seeking

    to cultivate well-being and support individuals in preventing and managing psychiatric disorders and optimizing their brain health.

    (Editorial comment: I feel some vexation about “lifestyle psychiatry” because I don’t think “lifestyle psychiatry” should be a specialty with its own textbook. Every psychiatrist should practice “lifestyle psychiatry”.) While the authors concede that “patients may have cost or access barriers to traditional care” and conclude the article with a proclamation that lifestyle psychiatry is “a vital component in improving the health and well-being of people around the world”, the final sentence gives away the underlying sentiment of bootstrapping: supporting “individuals in taking ownership of their mental health and well-being” (emphasis mine).

    The “social health” component from the Transdomain Model of Health is missing from “lifestyle psychiatry”, even though addressing social health will make it much easier for people to succeed in the “lifestyle psychiatry domains”:

    It’s much easier to get physical exercise when there are generous green spaces, plenty of intact sidewalks, and public safety isn’t a concern. Healthy diets and nutrition are easier to achieve when fresh food is available and affordable. It’s easier to be mindful and take yoga classes when you don’t have to work two jobs to make rent. People sleep better when there’s no noise pollution; what if the affordable housing wasn’t only close to airports, trains, and freeways? Neighborhoods with “third spaces” make social relationships more likely to bloom.

    To be fair, the lifestyle psychiatry authors do write of “consultation and leadership to governments, corporations, and health care systems” and informing “public education programs and community planners to support the creation of healthy communities [and] employers in creating healthy workplaces”. Their definitions, though, ultimately focus on individuals and do-it-yourself interventions with some consultation with your local lifestyle psychiatrist. (And, to be clear, I’m not saying that systems are the only issue. People do still need to make their own choices, but we can shift systems so it’s not as hard for people to make healthier choices. Life is already hard enough.)

    Seattle was not anywhere near the path of totality for the total solar eclipse today. Over lunch I watched part of NASA’s live broadcast. And what a mush ball I am: I cried into my meal as I watched the skies turn to black, heard the crowds cheer and gasp, and saw the dancing corona of the Sun.

    I’m not so naive to believe that being in community solves everything. However, I do believe that being in community–contributing to social health–can powerfully change the way we view and feel about ourselves, others, and the world around us. Millions of people witnessed a total solar eclipse in person or in two-dimensions today. I’m pretty sure I wasn’t the only one who cried while watching the broadcast. Three things had to be in place for this celestial event to occur: The Sun, the Moon, and the Earth. To witness this stellar occasion, we all had to be on the same planet. Maybe this is naive: I’d like to think that the shared experience of a total solar eclipse boosted our planetary social health. And, as a result, we individually experienced higher mental health today.