Category: Public health psychiatry

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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
COVID-19 Nonfiction Public health psychiatry

16 People.

Content warning: This post discusses death and suicide.

Photo by George Becker

Early in my training, someone older and wiser than me made a comment in passing:

There are two types of psychiatrists: Those who have had patients die by suicide, and those who have not.

I assume (perhaps incorrectly) that all psychiatrists eventually join the group where someone under their care dies by suicide. These deaths change us.

The first time I learned that someone under my care died from suicide was during my intern year. I didn’t know him well; I do not remember his name. I was working in a psychiatric unit in a hospital and had worked with him for only one or two days. He had a diagnosis of a psychotic disorder. My sole memory of him is his flat, unblinking expression while he looked at me. Though his face showed little emotion and he said few words, he radiated discomfort.

Within a week of his discharge from the hospital, he had jumped off of a bridge.

I didn’t know how to react. I don’t remember if we had a conversation about him, if anything else had happened, or what we could have done differently.

I do remember the name of the person who killed himself after he and I had been working with each for nearly a year. He was the first of “my” patients who died by suicide.

He earned a professional degree long ago, but was living in a shelter. Alcohol brought him comfort, though it drowned his career. He argued a lot. This was the primary way he knew how to interact with people. Despite his pugnacious manner, he and I built and maintained a respectful rapport.

The medical examiner ruled that he had died from an overdose, though the official did not deem this a suicide. The toxicology report stated that there was methadone and alcohol in his system. He did not like and never used opiates.

I still think of him a few times a year. I still wish he had talked to me before he ended his life.

In any given year, I learn that one or two people under my care have died. Most of the time, the cause isn’t suicide. People age; people get sick; bad luck strikes.

Between January of 2020 and June 2022, sixteen (16) people under my care died. None of them died from Covid. The youngest was in their late 20s; the oldest was in their mid-60s. A few died from suicide; others died from medical problems (some acute, some not). Many died from overdoses. Maybe they were intentional; maybe they weren’t. I will never know.

I recently spoke with a former colleague about the various losses we have experienced over the pandemic.

“No one wants to hear it,” she said with some bitterness. “People are tired of hearing sad or bad news, so they don’t ask about our work or how we’re doing.”

She’s not wrong. It’s not easy for me to talk about it, either, as talking about it means I have to think about it, and it’s hard to think about things that do not make sense and may never make sense: What happened? What happened to us?

Maybe I just want people to know that actual human beings died, that I knew these people, that all these people meant something to someone, that they meant something to all of us who had the opportunity to know them. I wish I could tell you more about the guy who made a handmade Christmas card for me, even though he had yelled at me the first time we met just six months prior. I wish I could tell you more about the woman who had several weeks of sobriety before she collapsed on the sidewalk, her heart pulseless. I wish I could tell you more about the man who always called me “Ms. Dr. Maria” and offered me home-cooked food whenever I visited him at his apartment.

That’s only three people. There are 13 others.

If you’ve lost someone during the pandemic, you are far from alone. A poll from 2021 (!) revealed that about 1 in 5 Americans are close with someone who has died of COVID-19. (Recall that over one million people in the US have died from Covid.) Suicide remains a leading cause of death in the US, with certain groups at higher risk than others. (Also remember that we all can help prevent suicides; it doesn’t have to be the only option.)

It’s okay to feel sad, angry, or disappointed; you feel how you feel. Things will change, as they always do, though they may not change as fast as we want them to. It’s also scary to express vulnerability. Voluntarily shedding the crusty carapace to reveal the soft tissue within, however, may be the best (or only) path forward.

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.

Categories
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.