Category: Systems

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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?

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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.

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Consult-Liaison COVID-19 Systems

Protecting Mental Health During a Pandemic.

For context for this post: In my opinion, the federal government under the 45th President failed in its pandemic response. The lack of federal leadership, coordination, and interventions have led to ongoing disorganization that adversely affects every single essential worker who currently provides health care and social services.

As the federal government has not provided any coherent response to the actual disease pandemic, I do not expect that it will provide any response to the psychological suffering that has already occurred and will continue to occur due to Covid-19. Since this administration ignored the National Security Council playbook on fighting pandemics, it seems likely that they will ignore resources that describe how to boost the morale and promote the mental health of its citizens.

As I work as a psychiatrist, I wondered in the early months of the pandemic what strategies nations had used in the past to support psychological health. My hope had been to apply these nation-level strategies to the organization I work in.

The resources weren’t hard to find. There were three documents that I found helpful:

Of the three, I found the Pan American Health Organization document to be the most useful. (One wonders if U.S. officials did not deign to read something from “those” countries.) It helped me frame challenges when talking with individuals and teams. It also helped me grasp the horrifying reality and anticipate heartbreaking consequences.

… not all the psychological and social problems that occur can be described as diseases; the majority are normal reactions to an abnormal situation.

This JAMA paper describes an increase in the prevalence of depression symptoms due to the pandemic. I appreciate that the authors did not state that there has been an increase in the prevalence of major depressive disorder. The pandemic is an abnormal situation. We cannot apply our usual definitions when nothing about this year is usual.

In a major catastrophe, grieving means dealing with many other losses and implies a broader, more community-oriented feeling. It implies interrupting a life plan that not only has a family dimension, but also a social, economic, and political one.

We’ve all lost so much. Some people have lost their lives; others have lost their health and wonder if they will ever get it back. People have lost jobs and are distressed about how they will pay for rent and food. Others have lost time and wonder how they will pay attention to things other than work and disease. Kids miss their friends and classmates; parents miss things that their kids don’t realize they’re missing. The use of screens has made life more two-dimensional, though many have lost more than one dimension in their lives.

… mental health plans cannot be limited to expanding and improving the specialized services offered directly to the people affected…

There are multiple reasons for this:

  • There aren’t enough mental health professionals to serve the entire population.
  • Many (most?) people do not need specialized services; they (we) just need more support.
  • Some professionals will diagnose illness and treat accordingly, when illness may not be present. (“When you only have a hammer, everything is a nail.”)
  • Specific communities will often provide more tailored and meaningful support to their members than professionals, specifically when grief is the diagnosis and support is the treatment. (What I say to an Irish dancer may not be as helpful as the support from the rest of the Irish dance troupe.)
  • Mental health professionals should focus their specialized expertise on people who are experiencing more severe symptoms and conditions.

Can and should people with specialized expertise, like psychiatrists, teach and train laypeople to provide support to their communities during and after a pandemic? I think so. (While not related to a pandemic, the Friendship Bench is an excellent example of training laypeople to provide valuable support to others.)

There are three basic messages:
1. We should not think only in terms of psychopathology, but also in broad terms about collective problems.
2. The area of expertise of mental health professionals needs to be expanded.
3. The majority of psychosocial problems can and should be addressed by nonspecialized personnel.

Most psychiatrists, like most physicians, are trained to treat individuals. Pandemics affect populations and our individual interventions are often ineffective and do not scale. Furthermore, some interventions done without care can cause harm (“benzos for everyone!”). Collective problems require collective solutions; expertise must be decentralized and shared; community members can provide good enough, if not better, support. The Psychological first aid during Ebola virus disease outbreaks provides a useful framework for this support.

A good mass communication strategy is critical to maintaining calm and an appropriate emotional state; a well-informed population can act appropriately, protect itself better, and be less vulnerable in terms of psychosocial aspects.

The federal administration has already demonstrated no interest in a “good mass communication strategy”, whether related to Covid-19 or other events. It didn’t have to be this way.

My hope is that, as the “C.D.C. and other public health institutions awaken from their politics-induced coma,” we will see not only the execution of a federal strategy to address the Covid-19 pandemic, but also the implementation of a federal strategy to support the nation’s mental health. 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.

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Consult-Liaison COVID-19 Homelessness Medicine Nonfiction Seattle Systems

“The Impact of Covid-19 on Homeless Services in Seattle.”

On Friday, I presented Grand Rounds to an agency in New York City. The title of my presentation was “The Impact of Covid-19 on Homeless Services in Seattle, Washington”. The audience was comprised mostly of psychiatrists who also work with people who are currently unhoused or have been homeless in the past.

In some ways, this presentation was easy to create: I simply described the agency I work for and walked the audience through the timeline of events:

While the Seattle-King County region was scrambling due to the first death from Covid-19, the first case of Covid-19 was diagnosed in New York City on March 1.

In other ways, this presentation is the only one I’ve made where I had to take breaks while making it because of anger, grief, and sadness.

The month of March was hectic for us and everyone else: We tossed routine policies out the window and scribbled new ones down. We shattered many of our old habits and hastily introduced new practices. Our collective workload increased significantly as we tried to be as flexible and responsive to the changes that were coming at us. We watched systems grind to a halt because systems can’t change that fast: We had to buy hand sanitizer from local distilleries and we donated N95 masks to hospitals. Systems that had long failed us suddenly had the harsh glow of media light on them: In all of Seattle, there were only five bathrooms with hand-washing sinks that were open 24/7. Congregate shelters, where over 200 people had no choice but to share one giant room and one bathroom, suddenly became unacceptable because the beds were not at least six feet apart.

And, yet, eight months later, not much changed. We haven’t had the opportunity to abandon restrictions; many of these new practices are now status quo because the situation hasn’t gotten better. I was honest with the audience: There was no resolution or hopeful conclusion at the end of my talk. Why was that? How could it be that, eight months later, things hadn’t actually changed much?

The audience said nothing. What is there to say? The lack of ownership and coordination at the federal level is the same now as it was in March/April. New York City has significantly more resources than Seattle, though those resources only go so far while SARS-CoV2 can cross state lines and national boundaries when no barriers are erected and no interventions happen. If people in a boat are not rowing in the same direction—or if people aren’t rowing at all—then the boat and everyone in it wastes a lot of time and energy.

I was surprised by the gifts of validation from the audience. Yes, we all work as psychiatrists and the last time most of us saw someone get intubated was when we were residents. However, we all recall doing consults on people in the ICU who were sick. Ostensibly, we were there to take care of the patient and maybe their family members. We also know, though, that an important (and often unspoken) part of psychiatric consults is to support the treating team.

We all have a sense of how terrible it is for the treating teams. These are the reasons why we desperately try to keep people healthy and out of hospitals. We know that our contributions are small—most people don’t live on the streets, in shelters, or in supportive housing; most people don’t have diagnoses of schizophrenia or severe substance use disorders—but we also know that our people are often maligned when they pass through the doors into traditional health care systems. We all have a sense of how terrible it is for our people. We also know that, due to the stress of living marginalized lives, our people often have more severe health conditions. They already have many risk factors that increase the likelihood of complications and death due to Covid-19. We’re trying to mitigate the stress of everyone involved.

It’s heartbreaking, terrible, and unfair.

To end the talk on a positive note, I mentioned several things I am grateful for:

  • The rainy season has arrived in Seattle and I get to sleep in a dry bed indoors.
  • I have confidence in where I am going to sleep tonight.
  • I have a job and can pay my bills.
  • I know I will eat (again!) today.
  • There now exists technology where I can speak to an audience of colleagues on the other side of the continent!

These both mean a lot and nothing at the same time.

In the meantime, we continue to do what we can while we wait.

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Systems

Revisiting Racism in Psychiatry.

While much of the current conversation has focused on racism within the criminal-legal system, institutional racism also exists elsewhere, including psychiatry.

I’ve written a few posts about this topic in the past:

Here’s one from 2017 that discusses “drapetomania“.

In 2018 I wrote about the use of race in advertisements for antipsychotic medication.

I also wrote about the intersections of race, jail, and psychiatry in 2017.

More to follow….