Category: Reading

New Year, New Reads.

Post author By Maria Yang, MD
Post date February 6, 2022

A new lunar year has arrived. May the year of the tiger bring us all better health and fortunes.

Here are some things I’ve read over the past week that may also be of interest to you:

If Everything Is ‘Trauma,’ Is Anything? “It’s hard to talk about this without sounding like you’re policing the language,” said Mr. Haslam. “But when we start to talk about ordinary adversities as ‘traumas’ there is a risk that we’ll see them as harder to overcome and see ourselves as more damaged by them.”

Impossible Silences. “They seem to me to be the kind of silences that are mutually felt and acknowledged, that are a function not merely of the ceasing of sound but of a body at ease or eyes that remain fixed. These are silences that assure the other that they are being heard not ignored. Silences that, if attended to closely and with care disclose rather than veil, clarify rather than obfuscate.”

Black History, Black Freedom and Black Love. “The three-part class, Black History, Black Freedom and Black Love will be freely available on MasterClass.com during Black History Month.” I must confess that it is John McWhorter‘s participation that tipped me to commit to watching this.

Fragrant Palm Leaves. The death of Thich Nhat Hanh prompted me to pick up this book. He writes more freely here than he does in his future books. I wonder who “Steve” is and if he is still alive.

The Reason Putin Would Risk War. “He is threatening to invade Ukraine because he wants democracy to fail—and not just in that country.” (There is plenty of troubling news within the US. There is a world stage to be aware of, too, though I wish the news were better.)

Public Mental Health Implementation Failure.

Post author By Maria Yang, MD
Post date January 23, 2022
1 Comment on Public Mental Health Implementation Failure.

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

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

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

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

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

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

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

The authors rightly comment

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

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

Insufficient public mental health knowledge
Insufficient mental health policy or policy implementation
Insufficient resources
Insufficient political will
Political nature of some [public mental health] activities
Insufficient appreciation of cultural differences
Causes of mental disorder treatment gap

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

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

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

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

COVID-19 Nonfiction Reading Reflection

Pictures in Time.

Post author By Maria Yang, MD
Post date September 12, 2021

The rocks of the mountain beneath your feet broke apart before you were born. Glaciers carved the valley before your eyes before your grandparents were alive. Trees towering overhead on this west coast sprouted before the ships from far away landed on the east coast. All of this was here long before you arrived and will persist long after you are gone.

History precedes you and the future remains unknown while you live in the present, where a pandemic persists. This tiny county that holds giant mountains reported two new deaths from Covid-19 this past week, leading to a total of 13 deaths over the course of this cursed pandemic. This number seems paltry compared to the 1,812 deaths in the county you live in, but for each death, many mourn.

Someone offered this idea to me a few years ago: You know those days when you feel sad, though there are no obvious, logical reasons as to why you feel sad? Maybe someone, somewhere, has died and there is no one left to grieve that death. Your sadness is a mourning of that death.

Maybe that, in part, is what we’re all experiencing now.

(I also did not realize that newspaper boxes are mirrors. Exhausted health care workers don’t expect to see exhausted health care workers on the front page of the local paper.)

Though we are exhausted—in varying degrees—and may wonder why we “spend” “our” time doing this work, perhaps this is how time is choosing to use us. Oliver Burkeman’s book Four Thousand Weeks is a gentle yet firm reminder that our time is finite, that only planning for the future logically means that we should only plan for death. That is what awaits all of us in our futures, right?

I highly recommend this book. (Bonus reason, beyond the content of the book: Mr. Burkeman sent a personal reply when I sent him a thank you note!) This choice did not diminish me; it enlarged me.

Sometimes reading about the past brings clarity to the present. The model Wilkerson puts forth in Caste about the relative status of Americans resonates with me (i.e., the actual issue is a caste system, where “race” is often the indicator). Her model better explains the interpersonal and inter-group dynamics of the US compared to solely race-based models. I also highly recommend this book.

Reading

The Challenge of Going Off Psychiatric Drugs for Psychiatry.

Post author By Maria Yang, MD
Post date April 7, 2019

Here are my initial reactions to the New Yorker’s The Challenge of Going Off Psychiatric Drugs:

Which populations are most likely to receive large numbers of psychiatric medications?

The woman described in the article comes from a family of money and privilege. These individuals (and families) have both the time and money to seek out psychiatrists who practice “precision psychopharmacology”. These psychiatrists then order complicated medication regimens that ostensibly address and “correct” neuroreceptors. As a consequence, people end up taking multiple medications.

There are also individuals who do not have money or privilege, but are subjected to psychiatric services due to the concerns of the public. They may be behaving in ways that endanger their own lives or the lives of others. As a consequence, they receive medications—sometimes willingly, sometimes through coercion—that aim to reduce certain behaviors. If one medication doesn’t reduce the behavior, then more are added.

What these two populations have in common are (a) the lack of clarity around diagnosis, which often stems from (b) missing information about the person and the context in which s/he lives.

I completely agree with Dr. Frances’s comment from the article:

[There is a] “cruel paradox: there’s a large population on the severe end of the spectrum who really need the medicine” and either don’t have access to treatment or avoid it because it is stigmatized in their community. At the same time, many others are “being overprescribed and then stay on the medications for years.”

The meanings of diagnosis and treatment, particularly medications.

Some people feel relief upon learning that their symptoms belong to a diagnosis, that what they have is “real”. Others don’t want the “label” of a psychiatric diagnosis; they are not damaged human beings.

For various reasons (e.g., the current primacy of biological psychiatry, insurance reimbursement, psychiatry’s seeming inferiority complex within medicine), treatment in psychiatry is often focused on medications. This is not ideal. Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.

In the meantime, doctors recommend that people take pills. Some people view pills as a necessary intervention to keep them healthy and well. Some people view pills as a shameful reminder that there is something wrong with them that will never improve. The more pills someone has to take, the more potent the reminder that they are beyond hope or repair. Some people view pills as an external validator of their pain and suffering: “Someone else believes and understands my pain and these pills remind them and me that my pain is real.”

The pills may not be treating what psychiatrists think they are treating.

The problems with psychiatric diagnosis.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) focuses only on the “what”, not the “why”.

It doesn’t matter why someone has a depressed mood, takes no pleasure in work or play, can’t sleep, won’t eat, and feels hopeless. The underlying reason could be the cardiologist’s realization that he should have pursued his dream of becoming an architect… or it could be the threat of eviction after losing one’s job.

This affects the way psychiatrists gather a history from people seeking care. Instead of learning the context behind one’s symptoms, psychiatrists now focus on whether certain symptoms are present or absent. What matters more is that she feels paranoid, not that the paranoia started when she learned that her father was molesting her sister.

To be clear, there are some instances in which the underlying “why” doesn’t matter. If someone is terrified of flying on a plane, there are treatments (e.g., exposure therapy) that can help people tolerate plane rides without getting into the reasons why this fear appeared in the first place.

In other instances, though, the “why” is often relevant. Since our understanding of the biology of the brain and mind are limited, we don’t know if the biological properties of Medication A are more useful in military veterans who have fought in combat or if those of Medication B are more useful in women who experience major depression after the birth of a baby. Even if evidence suggests that medications aren’t the best treatment for either population, it is often the easiest intervention to deliver. This is due to the context and underlying “whys” of the health care system.

All of the other psychiatrists.

It’s true that there is scant evidence about how to taper and stop medications. It is a shame that psychiatry, as a field, has nothing to say about deprescribing. The scientific literature has plenty to say about adding medications, but nothing that extols the virtues of taking them away. There are risks to stopping medications, yes, but why are psychiatrists unimpressed with the risks of starting them? In this way we have failed not only the people who receive care from us, but we also fail the people who step in to help in our absence: Other physicians, nurses, family members, friends.

When I consider the psychiatrists I have worked with with, many of them have helped people come off of medications. They work with their patients and go through the trial-and-error process together. While they may not work in ivory towers of acclaim, they are still doing the work of helping people make informed choices about their care so they can lead healthy and meaningful lives. These are the quiet anecdotes that will never make it into the New Yorker.

Psychiatry as an agent of social control.

This is not the first time I’ve written about psychiatry as an agent of social control.

What does it mean that “antidepressants are taken by one in five white American women”? Is this a reflection of white American women? Or a reflection of the society and systems that want to contain white American women?

What does it mean that African- and Latinx-Americans are more likely to receive diagnoses of psychotic disorders? Is this a reflection of these populations of color? Or a reflection of the society and systems that want to contain these populations?

Perhaps there needs to be a “Challenge of Going Off Psychiatric Drugs” for the field of psychiatry. To be clear, there is definitely a role for medications in the treatment of psychiatric disorders, though: first, do no harm. When The Royal We have more humility about what we do and do not know, and exercise more care in current pharmacological tools, then perhaps getting on or going off of psychiatric drugs won’t be a “challenge”.