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.

COVID-19 Homelessness Nonfiction Systems

The Third Line.

My eyes skimmed the document to find The Graph. Compared to past editions of the Behavioral Health Monthly Forecasts (that I described in a recent post), The Graph featured a third line:

The authors in the source document comment:

There are three behavioral health areas of focus:

(1) Omicron and other COVID variants: ongoing and
potentially severe disruptions to health care, social,
economic (supply chain), and educational systems caused
by the Omicron (and potentially other) variant(s).

(2) Children, youth, and young adults: concerning behavioral
health trends for children, youth, and young adults.

(3) Collective grief and loss: not just related to the loss of
individuals, but social and systemic losses as well.

How do we reconcile the three areas of focus above with the three lines in the graph? Are the people in the top yellow line experiencing collective grief and loss? Is it just a matter of degree across the three lines, depending on how much people have lost?

While wondering about this, I came across this article: How Epidemics End. I was surprised to learn that this article was published two thousand years ago in June of 2020. Vaccines weren’t even available at that time. (It’s hard for me to believe that it was only just over a year ago that I received my second Covid vaccination.) The tag line summarizes a major point in article: “History shows that outbreaks often have murky outcomes—including simply being forgotten about, or dismissed as someone else’s problem.”

Of course pandemics don’t just abruptly end. The authors note that “epidemics are not merely biological phenomena. They are inevitably framed and shaped by our social responses to them, from beginning to end”. They then describe societal reactions to the 1918 flu pandemic, the 2002 SARS epidemic, and the adoption of the polio vaccine. There is no “singular endpoint”; rather, epidemics end:

  • when there is “widespread acceptance of a newly endemic state” (like HIV)
  • “not when biological transmission has ended… but rather when, in the attention of the general public and in the judgment of certain media and political elites who shape that attention, the disease ceases to be newsworthy” (like polio)
  • when the new disease in question emerges abruptly, rather than gradually (like Legionella and tuberculosis)

In forecasting the end of the Covid pandemic, they comment:

At their best, epidemic endings are a form of relief for the mainstream “we” that can pick up the pieces and reconstitute a normal life. At their worst, epidemic endings are a form of collective amnesia, transmuting the disease that remains into merely someone else’s problem.

That brings me back to the third line, the lowest line, in the graph above. It is not with pride that I recognize that I, along with many of my colleagues, are following the course of the lowest line. It also brings me no satisfaction to acknowledge that the Covid pandemic will likely end for the majority of people in the US before it ends for those of us who work in and use safety net programs, such as emergency departments, homeless shelters, and immigrant and refugee clinics. (When I consider the consequences for other nations, the weight of sadness feels great: There are many people around the world who want to receive a vaccine, but still have not gotten their first dose. The pandemic will also continue for them after it has ended for many others.)

Back in December 2020, I counseled myself:

For those of us in the third line, it has become more difficult to answer either question with confidence.

COVID-19 Homelessness Nonfiction Public health psychiatry Seattle Systems

Faltering and Failing.

The omicron variant has resulted in a surge of cases here in Seattle-King County:

Our hospitals have not been spared. They, like in other areas, are in a crisis situation:

There are similar surges in Covid cases in homeless shelters and other congregate settings. This, combined with an insufficient number of people who are willing and able to work at isolation and quarantine (I&Q) sites, has led the I&Q sites to limit the number of admissions. The admission criteria now are the most stringent they have been at any point during the pandemic:

What this means in practice is that people living in shelters who are sick with Covid may have nowhere else to go. If they are lucky, they will be able to stay in the shelter. Their only other option may be staying outside in the chill and darkness of January.

Which is worse? Covid infections sweeping through a homeless shelter? Or people exiled outside because they are sick? (They may end up seeking help at an emergency department, all of which are already strained and overburdened.)

To be clear, I do not blame the county for this. Health care workers are fleeing their jobs due to the crush of the pandemic. Everyone is struggling with hiring health care and essential workers.

We cannot look away from the horror of systems faltering and failing. We must witness that the most vulnerable people in our community will bear the greatest brunt of these failures.

COVID-19 Nonfiction Policy Public health psychiatry Systems

Pandemic of Demoralization.

I haven’t posted much recently because I don’t want to be a bummer. There’s enough of that in the world right now: disasters on a global scale and quiet tragedies just down the block.

I worry about the health care workforce. While it is indeed a privilege to go to school to learn about illness and health and then apply those skills to people who somehow trust us, this pandemic has squeezed and stretched us in ways none of us could anticipate. Not only do we see people who get sick with Covid-19, but we also see all the people who get sick from everything else because of the system pressures and failures due to Covid-19.

I see the fatigue on my colleagues’ faces; I see their struggles in trying to provide the best care they can when they themselves are not thinking or feeling their best—now going on for over a year.

We all remain focused on the Covid pandemic, though the demoralization[1. “Demoralization is a feeling state of dejection, hopelessness, and a sense of personal “incompetence” that may be tied to a loss of or threat to one’s own goals or values.”] pandemic has already descended upon us. While the pandemic has fostered more conversations about mental distress and illness, no robust system has emerged to take care of those who take care of others.[2. It is not only health care workers who would benefit from care from people and systems.] (How could we expect a robust system to emerge when the system—if there was one—was fragile prior to this pandemic?) This distress manifests in dreams and dissociation, prickliness and physical pain, withdrawal and wretchedness.

I never formulated my specific work as “public health psychiatry”, though, in the months before the pandemic, this idea crystalized in my mind. Most of my career has focused on the “deep end” of the system: homelessness, crisis, jails, and poverty. While people can and do get better, the challenges are great when one is reacting to, rather than navigating through, these barriers and systems.

So much of what I do is tertiary prevention (“managing disease post diagnosis to slow or stop disease progression“). Fewer people would need “deep end” services if there were more agile and reliable primary and secondary prevention systems. How much healthier would people be if they were never sexually assaulted as children? if parents were able to feed themselves and their children with confidence? if everyone had a stable and safe place to live?

For our health care workforce now, it is too late to prevent demoralization and exhaustion. It seems that the best that we can do is prevent more harm from happening. Tertiary prevention is still prevention, though this is hard to reconcile with the realities of our daily work: Will tertiary prevention buoy us enough so that we can give good enough care to our patients?

Consult-Liaison Education Medicine Nonfiction Systems

More Annotations on the Britney Spears Transcript.

I have not paid close attention to news about Ms. Britney Spears’s conservatorship over the years, though was interested to learn what she recently had to say about it. I felt both sad and disturbed after I read her remarks. (Here’s an audio recording, too.)

To be clear, I don’t know anything about her, her diagnoses, or the specific details of medical care she has received. Despite spending most of my career working with people with conditions like schizophrenia, bipolar disorder, cognitive impairment, substance use disorders, and often major medical conditions, I have referred very few people for guardianship… and none of them presented like Ms. Spears. I have never provided care to public figures or similar VIPs.

Following are the reactions and questions I had upon reading the annotated transcript of her testimony, for your consideration:

They all said I wasn’t participating in rehearsals and I never agreed to take my medication, which, my medication is only taken in the mornings, never at rehearsal.

I don’t know what medications she takes. If she is referring to any psychiatric medication here, this hopefully suggests that her medications cause only minimal, if any, sedation. Many medications usually prescribed for conditions like schizophrenia and bipolar disorder can make people feel tired, sleepy, or sluggish, particularly when people first start taking them.

I was told by my at-the-time therapist — Dr. Benson, who died — that my manager called him in that moment and told him that I wasn’t cooperating or following the guidelines in rehearsals.

I don’t know the terms of her conservatorship, though it is uncommon for managers to be able to call a patient’s therapist or doctor. Can you imagine if your boss were able to call your doctor to report that you weren’t “cooperating or following guidelines”?

Maybe there are releases on information on file for her manager and doctor to talk to each other, though most people don’t want to mix their personal and professional lives like this. That being said, I have had friends or parents of people under my care call me to share information with me, though they understood that I would say nothing in response. I’ve never had a teacher or boss call me, though.

And he also said I wasn’t taking my medication, which is so dumb because I’ve had the same lady every morning for the past eight years give me my same medication, and I’m nowhere near these stupid people.

So many questions here! Who is this “same lady”? Is this a health care professional, like a nurse? For “every morning”? For the “past eight years”? Does she actually need someone to give her medications every morning? Is she unable to do this herself? (This seems unlikely if she is able to “[rehearse] four days a week”, “[direct] most of the show”, and “[do] most of the choreography”.) Or is the purpose of this “lady” to enforce and report compliance? The usual goal is to help promote people’s autonomy and independence, since no one wants to undergo monitoring like this… especially for eight years!

Presumably this “lady” is also using a medication administration record for Ms. Spears so there is written proof of what she is or is not taking. This might be one way the therapist would know that she “wasn’t taking [her] medication”.

Three days later, after I said no to Vegas, my therapist sat me down in a room and said that he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false.

An accurate and truthful medication adherence record would provide proof to both Ms. Spears and her therapist about whether she was taking her medication. This is a document that attorneys, judges, and other people could review.

He immediately, the next day, put me on lithium, out of nowhere. He took me off my normal meds I’ve been on for five years…

If I am reading this right, this means she was under medication administration monitoring for eight years and had been taking the same medications for at least five years (though she said eight years earlier). This suggests a stable medication regimen that she was able to tolerate.

… lithium is a very, very strong and completely different medication compared to what I was used to.

Lithium started at aggressive doses can indeed be “very, very strong”. “Strong” doses of lithium are most often used for people experiencing “mania”, which is a component of bipolar disorder. “Mania” doesn’t mean someone who is “happy” or simply “euphoric”. Mania, in its more extreme forms, looks like increasing amounts of energy in the context of decreased sleep (sometimes for only a few hours, if at all) for many nights, sometimes lasting weeks. People often demonstrate significant changes in behavior during this period of time, such as spending large sums of money they don’t have (e.g., via credit cards) and doing impulsive things that are uncharacteristic of them (e.g., starting businesses with no foundation, having sex with people they don’t know, using drugs or alcohol). Sometimes these combination of behaviors are lethal: People will jump from heights, having full confidence that they can fly.

The thing is, lithium usually doesn’t work that fast. Usually people who are experiencing mania receive lithium to prevent the next episode. They also take something else (ideally for a short period of time) to treat the current episode.

You can go mentally impaired if you take too much, if you stay on it longer than five months.

I don’t know what she means here. Some people take lithium for years (decades!) and they do not “go mentally impaired”. In fact, lithium can be literally lifesaving and keep people well and out of the hospital.

Lithium at high doses, if not properly monitored, can cause sudden changes in mental status and emergency medical problems.

But he put me on that, and I felt drunk.

Yes, this can happen, particularly if the starting dose is high.

I told them I was scared and my doctor had me on — six different nurses with this new medication come to my home, stay with me to monitor me on this new medication, which I never wanted to be on to begin with. There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.

Six different nurses? Who were staying with her? When people (recall that my experience is limited to non-VIPs, which makes up most of us) are in an intensive care unit (ICU) for a major medical problem, there’s ideally one nurse working with only two patients. Six nurses to one patient is a lot. Maybe she meant she worked with six different nurses, but there was only one nurse in her home at any given time?

People who start taking lithium at conservative doses don’t need this level of monitoring. People who start taking lithium are often still working, taking care of their kids, going to school, etc. When people start taking lithium in a psychiatric hospital, this intensity of monitoring doesn’t happen.

Lithium can be sedating, particularly at high doses, which might be why these nurses prohibited her from driving. But for a month? Does this mean that the dose of lithium was changing/increasing over the course of the month? Or they were overly cautious?

He acted like he didn’t know, but I was told I had to be tested over the Christmas holidays before they sent me away when my kids went home to Louisiana.

It seems that she means psychological testing here, though perhaps this also included getting blood drawn to check the amount of lithium in her blood? This latter bit is called a “lithium level”. As noted above, high levels of lithium can be toxic, so people who take lithium get “lithium levels” drawn on a routine basis to ensure that the levels are not near/at toxic levels. Lithium can also affect the function of kidneys and the thyroid gland, so health care professionals often check these labs, too. If the blood draw doesn’t show any lithium, then that means the person hasn’t been taking it.

Over the two-week holiday, a lady came into my home for four hours a day, sat me down and did a psych test on me. It took forever. But I was told I had to. Then, after I got a phone call from my dad saying, after I did the psych test with this lady, basically saying I’d failed the test or whatever.

I don’t know what this is, either. Did the “psych test” last four hours? (Was it a Structured Clinical Interview for DSM-5? I am skeptical: Why would someone start a medication and then do a “psych test”?)

If you don’t build rapport with people, they will provide incomplete or inaccurate information to you. The onus is on the interviewer to build rapport with the patient. I don’t know what it means to “fail” a “psych test”.

“I’m sorry, Britney, you have to listen to your doctors. They’re planning to send you to a small home in Beverly Hills to do a small rehab program that we’re going to make up for you. You’re going to pay $60,000 a month for this.”

I don’t know what “rehab program” means here. “Rehab” often refers to treatment for substance use disorders, though there are no indications to use lithium for substance use disorders. Psychiatric rehabilitation is also a thing, though this usually refers to providing education and support to people regarding social skills, gaining independence, and other strategies to prevent return to psychiatric hospitals and other intensive models of care. The goal is to keep people in the community and away from institutions.

I worked seven days a week, no days off, which in California the only similar thing to this is called sex trafficking, making anyone work, work against their will, taking all their possessions away — credit card, cash, phone, passport card — and placing them in a home where they work with the people who live with them. They all lived in the house with me — the nurses, the 24-7 security. There was one chef that came there and cooked for me daily, during the weekdays. They watched me change every day — naked — morning, noon, and night. My body — I had no privacy door for my room, I gave eight gals of blood a week.

This sounds like an extreme and unethical version of a “therapeutic community”. (The evidence supporting the application of therapeutic communities isn’t great, though some people who have gone through such programs swear by it.) This sounds more like an upscale jail, which, to be clear, is still a jail.

Humans hold less than two gallons of blood, so I don’t know what she means here. Did she undergo a lot of blood draws? To check her lithium level? To monitor whether she was using any drugs or alcohol? (Checking urine is a less invasive way of doing this.)

And ma’am, I will tell you, sitting in a chair 10 hours a day, seven days a week, it ain’t fun. And especially when you can’t walk out the front door.

If she spent most of her time “sitting in a chair”, then maybe this wasn’t a therapeutic community (and more like jail). People usually have to do chores and attend meetings in therapeutic communities. People in (non-VIP) psychiatric hospitals also don’t spend 10 hours sitting in a chair for seven days a week.

I don’t even drink alcohol — I should drink alcohol considering what they put my heart through. Also the Bridges facility they sent me to…

Today I learned about Bridges to Recovery, “residential mental health treatment in a private, luxury environment”. Is this where she went? Bridges to Recovery is part of Constellation Behavioral Health, which is owned by New MainStream Capital.

New MainStream Capital is a “private investment firm specializing in strategic equity investments in leading middle market companies with an emphasis on sustainable growth trends in both the business services and healthcare services industries.” This tells me that they are more interested in getting as much return on investment for their shareholders than providing quality care to people at Bridges to Recovery.

They have me going to therapy twice a week and a psychiatrist. I’ve never in the past had — wait, they have me going, yeah, twice a week, and Dr. [unclear] — so that’s three times a week. I’ve never in the past had to see a therapist more than once a week.

Yes, that’s a lot of therapy. People who participate in psychoanalysis go to therapy four to five times a week. However, psychoanalysis under normal circumstances is a voluntary process. (Full disclosure: I am biased against psychoanalysis.) If the psychiatrist is providing medication services only, that’s a lot of psychiatrist visits. Maybe they know a lot more than I do: How much meaningful medication tinkering can a psychiatrist do with meds every week, when the mechanism of action for so many psychiatric medications remains unknown? (Exhibit A: The serotonin hypothesis.)

I have a friend that I used to do AA meetings with. I did AA for two years. I did three meetings a week. I’ve met a bunch of women there. And I’m not able to see my friends that live eight minutes away from me, which I find extremely strange.

It sounds like Ms. Spears found AA helpful because of the support she got from her community. Much of what she reported in the transcript sounds like absence of community, which of course will have negative effects on her mental health and wellbeing.

I wanted to take the ID [IUD] out so I could start trying to have another baby. But this so-called team won’t let me go to the doctor to take it out because they don’t want me to have children, any more children.

Many have already commented on her statement that she is not allowed to remove her IUD and how this relates to reproductive justice. This also makes me wonder if she is taking any medications that might result in birth defects.

I am sorry to say that I have had women under my care who underwent involuntary hysterectomies due to their psychiatric conditions. All of these women were in their 70s and 80s, so none of these were recent events, but these women usually were not told that their uteruses were surgically removed until after the fact. By the time I saw them, they were taking minimal (if any) psychiatric medications and were not demonstrating symptoms that would warrant an irreversible intervention without any discussion about it.

There is so much that we don’t know about Ms. Spears and what has happened. I only hope that, if she has experienced injustice at the hands of individuals or systems, she will be vindicated and systems will change for the better.