Category: Public health psychiatry

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Education Medicine Policy Public health psychiatry Systems

What is Mental Health? (02)

To continue from my last post about “what is mental health?” and “what am I doing?”, let’s look at another figure from the paper What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey:

Figure 2C

This model argues that an individual’s mental health isn’t the sole product of that single person (because, yes, things are complex). “Society” also contributes to and affects a person’s mental health.1

The Covid pandemic provided plenty of empirical evidence that “society” has enormous influence on the mental health of individuals. Over a third of young people reported “poor mental health” and nearly half reported they “persistently felt sad or hopeless” in 2021. There were nearly 30,000 (!) more deaths related to alcohol when comparing 2019 to 2021. Two out of every five adults reported “high levels of psychological distress” at some point during the pandemic.2

The pandemic isn’t the only example of the power of “society” on mental health. Survivors of mass shootings can develop psychiatric symptoms or disorders. Residents of Flint, Michigan, could only access drinking water contaminated with bacteria, disinfectants, and lead. This contributed to elevated rates of psychological conditions like depression and PTSD. Poverty increases the likelihood of depression and anxiety.

“Imagine how many people I wouldn’t need to see if people never experienced homelessness!” I mutter (or exclaim) at least once a month. It’s not just homelessness: It’s working three jobs to make rent; it’s trying to keep the family fed and housed when one parent has major medical problems; it’s trying to leave an abusive partner; it’s trying to keep things together when a family member has an alcohol or gambling problem. Because much of my career has been in the “deep end” of the system, I often witness how misaligned and rigid institutions often bruise and scar the psyches of individuals and populations of people.

Maybe context matters more in psychiatry than in other fields of medicine. When I think, “What am I doing?”, I often wonder if I should work “upstream” in prevention and early intervention to help change these contexts. This includes advocacy for action that is outside the purview of medicine, such as lowering barriers to housing or increasing regulation of firearms.

Some physicians (and others) have argued that doctors should “stay in our lane”, that we should focus on treating conditions that we are trained to treat. Medical school didn’t teach me how to prevent psychotic disorders; it trained me to identify and treat schizophrenia. In residency I didn’t learn how to develop policy and programming to prevent war and rape; I was trained to provide care and support to someone with PTSD. I can help someone choose to put their gun away so they don’t shoot themselves; I don’t know how to organize people to persuade elected officials to change gun regulations.3

Of course, there’s a middle ground. My clinical experience and expertise give me the anecdotes and data to advocate for system changes. These system changes can improve the health of individual people. Furthermore, there are real people who have real psychiatric problems who need real help right now. As Paul Farmer said,

To give priority to prevention is to sentence them to death—almost to urge them to get out of the way so that the serious business of prevention can start.

I once worked for a medical director who often said, “I’d love to work myself out of a job.” It sounds disingenuous, but it’s true: I completely agree. How wonderful would it be if fewer people experienced psychological distress and problems with living! (Given the ongoing shortage of psychiatrists and other mental health professionals, this would be a win for literally everybody.) What if people didn’t believe that suicide was the best option? Or if people didn’t have to grapple with unending worry about where they will sleep tonight or when their next meal would be? I wholeheartedly concede that crafting legislative language and designing policies and programs are not my strengths. However, it also makes little sense to me to keep my head down and simply treat illnesses and suffering that can be prevented. Things don’t have to be this way.

(1) Again, if we’re going to be picky about words, I prefer the word “context” over “society”. “Society” suggests something uniform, when there exist microcultures within one society. For example, I’ve worked as a homeless outreach psychiatrist in New York City and Seattle. In New York I wore bright blouses with large ascots. In Seattle I wear dark hoodies. Same job, same society, different contexts.

(2) We can argue about whether these reports of distress and their associated behaviors reflect “mental illness” versus “mental unwellness”, in reference to part one of this series.

(3) While media reporting often focuses on guns and homicide, firearms cause more suicides than homicides.

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Consult-Liaison Education Medicine Public health psychiatry Reading

What is Mental Health? (01)

To try to answer the perennial question I ask myself (“what am I doing?”), I recently read this 2015 article, What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey.

As a psychiatrist1, do I treat mental illness? What is mental illness? What is mental health?

The paper comments on the ambiguity in the definition of “mental health”:

Mental health can be defined as the absence of mental disease or it can be defined as a state of being that also includes the biological, psychological or social factors which contribute to an individual’s mental state and ability to function within the environment.

Upon reading this I recognized that I define “mental health” according to the second definition, “a state of being…”. This also explains why I internally bristle when people say “mental health” when they actually mean “mental illness”. (Example: The Lancet Commission on ending stigma and discrimination in mental health.)

Figure 2B, the Two Continua Model, resonates with me:

There are people with diagnoses of significant mental illnesses who have “high mental health”. (If we’re going to be picky about words, I’m not sure that I like grading mental health as “high” or “low”. Maybe “well” versus “unwell”? It is more common to hear “I’m physically doing well,” rather than “My physical health is high.”)

Consider the person with a diagnosis of schizophrenia who has been hospitalized multiple times in the past. However, now they go about their lives and only make contact with their healthcare team every few months for routine check-ins.2

Then there are people with no diagnosable mental illness who have “low mental health”. Consider the many people who felt psychologically unwell during the Covid pandemic.

I started doodling to try to determine where psychiatry should intervene along the axes of mental illness and mental wellness:

I have yet to come up with any convincing answers. This doodling did offer clarity, though:

My professional interest has been the diagnosing and treatment of (often severe) mental illness. There are many reasons for this. One compelling reason is that the severity of symptoms makes it unmistakable that professional intervention is warranted.3

Only after years had passed did I recognize that this worldview is why I chafed at some requests patients brought to me early in my career. I once went through an entire diagnostic interview with a guy who worked as a game designer. Nothing came up; according to the Two Continua Model, he had neither a mental illness nor low mental health. Only at the end did he reveal why he had sought care from a psychiatrist: “My girlfriend takes Prozac and it made her more creative. I thought that if I take Prozac, that might make me creative, too, which can help me with my work.”

My goal was to diagnose and treat a mental illness. His goal was mental enhancement.

Are these two goals mutually exclusive? I don’t think so, though I want to noodle on this more.

The history of psychiatry holds these two goals in tension, too: On one end are the state psychiatric hospitals (also called asylums) where some people with severe symptoms (or not) were held (warehoused?) prior to the elimination of these institutions. On the other end are the psychoanalysts, where the typical patient was “a college-educated, upper-middle class professional who paid for service out of pocket.”

More to follow as I continue to wonder what I am doing.

  1. It was never part of The Plan to become a psychiatrist. This is part of the reason why I ask myself the perennial question, “What am I doing?”
  2. When asked, “What is your best life?”, no one responds, “I want to spend as many precious moments of my existence in hospitals and clinics.”
  3. A choice quote from the paper that highlights why I personally like clarity about where professional intervention is warranted: “Lots of things can cause people problems—poverty, vices, social injustice, stupidity—a definition of health should not end up defining these as medical problems.”
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Education Lessons Public health psychiatry

Watch for the Political Abuse of Psychiatry.

The Lancet recently reported that women in Iran who disobey religious law by refusing to wear a hijab are being diagnosed with antisocial personality disorder. These women subsequently “undergo psychotherapy treatment” and must provide “mental health recovery certificates”.

The article also refers to this piece, Iran sentences unveiled women to jail, washing dead bodies in a cemetery and undergoing therapy, that reports a

ruling by a third criminal court in Tehran defining not wearing the veil as “a contagious mental illness that causes sexual promiscuity.” The defendant was sentenced to two months in prison and ordered to pay for six months of psychological treatment.”

(It’s unclear what “psychotherapy / psychological treatment” means. This is likely intentional.)

Do women in Iran who refuse to wear a head covering truly have antisocial personality disorder?

Here are the primary DSM-5 criteria, which are similar to the criteria in ICD-10:

A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

  1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
  2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
  3. Impulsivity or failure to plan ahead.
  4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
  5. Reckless disregard for safety of self or others.
  6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
  7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

The key here is disregard for and violation of the rights of others. I am unfamiliar with Iranian religious law, though it is hard to understand how a woman who is not wearing a head covering is disregarding and violating the rights of others. Is the argument that the hair of women impinges on the rights of men? What freedoms are taken from men when they see women’s hair? What freedoms are returned to them when women’s heads are covered?

However, it’s also not hard to see how one can twist the criteria for women to receive a diagnosis of antisocial personality disorder:

Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. Women are required to wear a hijab by law. Women who don’t cover their heads are breaking social norms and the law.

Impulsivity or failure to plan ahead. Wearing a hijab requires planning. Only someone who is impulsive or short-sighted would forget to wear a hijab when going out.

Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. A responsible woman would consistently wear hijab.

Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. Women who refuse to wear a hijab are unapologetic about their behavior. They clearly don’t care about the disrespect they are showing to religious law.

That’s four criteria when only three are required. Though it’s still unclear whose rights are being violated, the twisting of criteria is easy to do to distract from the intentional distortion of context.

The Lancet article correctly notes that the “diagnosis” of women who refuse to wear hijabs and their subsequent “treatment” is political abuse of psychiatry. One of the authors, Robert van Voren, has written other articles on this topic, including Political Abuse of Psychiatry—An [sic] Historical Overview, where he teaches us that the Soviet Union was a major culprit:

Socialist ideology is focused on the establishment of the ideal society, where all are equal and all will be happy, and thus, those who are against must be mad. … The political abuse of psychiatry in the Soviet Union originated from the concept that persons who opposed the Soviet regime were mentally ill because there was no other logical explanation why one would oppose the best sociopolitical system in the world.

In a separate article, Ending political abuse of psychiatry: where we are at and what needs to be done, van Voren argues that regimes abuse psychiatry because “in most cases it is a combination of expedience and ideology.” He goes on to note:

Sending people to a psychiatric institution is particularly practical because hospitalisation has no end and thus, if need be, people can be locked away forever, or as long as they continue to have views that are considered politically or socially dangerous, or remain inconvenient to the authorities. … At the same time, declaring a person mentally ill provides a perfect opportunity not to have to respond to their political or religious convictions, as they are the product of an ill mind and do not have to be taken seriously.

He argues that the way to combat political abuse of psychiatry is similar to combating misinformation:

stimulating communication and access, providing training in issues of medical ethics and human rights, and translating key documents and manuals into local languages may make it impossible for the public to remain uninformed.

Why am I writing about abuses of psychiatry in Iran? With increasing overt conflict between and within nations, psychiatrists and other mental health professionals should know the history (some of it recent!) of the political abuse of psychiatry. None of us are immune to persuasion and coercion. Though I hope that governments and other authorities will never ask us to use our skills to harm people, hope is not a strategy. People in power can exhibit antisocial behaviors, too. Democracy may decrease the likelihood that psychiatrists will succumb to political pressure, though psychiatrists are still people. Most people avoid conflict, respond to incentives, and do not want their status to drop. Psychiatrists are not morally invincible.

The public also needs to know this history. (I recognize I am but a tiny fish in the ocean that is the internet. I appreciate that anyone is willing to give the gift of attention to my writing here.) If psychiatrists and other mental health professionals start “treating” people whose only symptom is having an opinion that diverges from the government’s perspective and propaganda, we need the public to call this out.

Hospitals have better food, softer linens, and more space than jail, but both places can restrict your movements and prevent you from leaving. Psychotherapy can be harmful and punishing. The stigma of mental illness and treatment, while decreased over the past few years due to the pandemic, persists and can be used to reject and dismiss people.

Civil disobedience doesn’t disregard and violate the rights of others.

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Public health psychiatry

Killing and Mental Disorders.

Though over three years have passed since the start of the pandemic, we on Earth have yet to escape the specters of death and destruction. With murderous tragedies large and small happening around the globe, one might wonder, “All these people who are killing other people: There must be something wrong with them. Do they have a mental disorder?”

The Diagnostic and Statistical Manual, now in its fifth, text-revised edition, provides this definition for “mental disorder” (emphases mine):

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.

Let’s consider some examples:

The man who shot 18 people in Maine. There are accounts that he has heard voices in the recent past. It is unclear if these voices were related to his threats to carry out a shooting at a military base. Reporting suggests that these two events resulted in a psychiatric hospitalization.

If we assume that he is still experiencing now the symptoms he had over the summer, he has a disturbance in his cognition (hearing voices) and behavior (use of a firearm to kill other people). We don’t know if the voices have caused him distress. He is certainly experiencing major disability at this time, as it seems that he has no social connections at this moment and he isn’t able to engage in activities such as work and leisure. He has demonstrated socially deviant behavior that, at least the way it is reported, is related to a dysfunction inherent to him.

Thus, it seems likely that this man who has killed 18 people in Maine has a mental disorder.

The Long Island Sex Killer. This is the man who allegedly killed 11 women between 1996 and 2011 and put their remains on Gilgo Beach. This man worked as an architect in New York City, was married, and had children.

It is debatable if he had a clinically significant disturbance in his thoughts, emotions, and behaviors: No one in his life seemed to notice any disturbances. For 15 years he presumably didn’t exhibit concerning distress or disability, as he was able to maintain multiple roles in his life with success. No one knew of his socially deviant behavior until he was caught.

Under this framework and given what has been shared, the Long Island Sex Killer does not appear to have a mental disorder.

People fighting in wars. This can include a military attacking an opposing nation-state, an organization attacking a nation-state, or a nation-state attacking an exclave.

We’ve already encountered a barrier: Mental disorders, by definition, only occur in individuals, not populations.

So let’s broadly consider the leadership of these populations, such as elected officials and others with high rank and authority. Propaganda obscures whether any of them are exhibiting disturbances. Note that their followers would not interpret their leaders’ thoughts, emotions, and behaviors as disturbed. Any distress the leaders express is related to their rage towards the enemy. Anyone showing disability would likely be removed, as this would be construed as a vulnerability. Attacking the enemy is not socially deviant behavior. (Resisting such efforts is.)

Leaders who order the killing of other people, in this framework, do not have mental disorders.

(As you already know, those fighting and harmed in wars are at higher risk of developing mental disorders. It is unjust that once someone demonstrates disturbances, distress, and disability due to war, the consequences of a state action land solely on individuals who must bear the psychological burdens and stigma.)

So, if mental disorders are not the underlying reason why people kill other people, then what is?

(Evil?)

(If it is evil, that is not something psychiatrists can treat.)

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Homelessness Nonfiction Policy Public health psychiatry

Age and Vulnerability.

She was unprepared: One woolen blanket was wrapped around her shoulders. The other one was spread out so she did not have to sit directly on the ivy and weeds crawling across the hillside. A nylon sheet was rumpled by her side. Behind her was a pushcart that held a thin roll of garbage bags and a small empty cardboard box. There was no tent or sleeping bag. Though there were other people higher on the hillside, there was no one within earshot.

Most of the pages in her notebook were blank. The pen ink was bright turquoise; her penmanship was small and neat.

Small metal studs adorned her ears and a chunky chain was around her slender neck. Her hair was dyed an unnatural color and showed no signs of fading. The only hints that revealed that was not brand new to the hillside were the dust on her fashionable sneakers and the dirt that was collecting underneath her short fingernails. She also said that her phone had run out of charge.

She is not yet 20 years old.

I don’t expect that they are still alive, though I still think of them even when I’m not visiting New York City.

I met her when she was in her mid-60s. She never told us where she slept, though we reliably found her at the ferry terminal. Her fingers moved the needle and thread with ease to close the hole in her sock. She kept spools of thread in a plastic container that sat on the bundle of clothes she packed into her pushcart. Despite our best efforts for over two years, she never accepted housing: “The aliens will exterminate me if I go inside.”

I met him when he was in his 70s, or so we thought. No one knew his birthdate; he never shared this information. He buried himself between mounds of full trashbags or folded himself into cardboard boxes lining the curb. On the few occasions he spoke, the thinness of his voice—sometimes so faint that it seemed that only wisps of his speech reached my ears—betrayed his age.

Back here in Seattle, as elsewhere, there are people in their 70s and 80s who live outside or in shelters.

People under the age of 25 who are on their own and homeless are called “unaccompanied youth”. They are “considered vulnerable due to their age”. These unaccompanied youth make up about 5% of the homeless population in the US.

As the US population ages, people who are homeless are also aging. A study of homeless people in California found that 47% of all homeless adults are 50 years of age or older. Even more alarming, nearly half of all homeless people over 50 years of age first became homeless after they turned 50 years old!

Why do we consider “extremes” of age (though being in your late teens or your 70s is not actually “extreme”) as a factor that contributes to vulnerability when homeless? If you’re a 51 year-old man and you don’t know where you’re going to sleep tonight, doesn’t the variable of not knowing where you’re going to sleep tonight automatically make you vulnerable? Sure, you may have the size and mass to successfully defend yourself if someone attacks you or the ability to endure nighttime temperatures, but is that really where we’ve set the bar for vulnerability?