Sunday, March 04, 2018
In the New York Times, Benjamin Weiser has a beautiful and moving story about Nakesha Williams, a lovely and vibrant woman who graduated from Williams College and then became ill with a psychotic disorder. She lived for years on the street in New York City. Please do surf over to Mr. Weiser's story, "A 'Bright Light' Dimmed in the Shadows of Homelessness."
The story is a tragic one about a promising woman whose future, and ultimately her life, are lost to mental illness. Despite so many people who loved and cared about her, and so many who tried to get her help, Ms. Williams dies alone on the street. She is young, and she dies of a treatable disease, a pulmonary embolism. Mr. Weiser does a commendable job of re-creating her story and tracking down the people who knew her in the years before and during her psychiatric decline. To his credit, he just tells the story; he doesn't turn it into a plea for laws that make it easier to involuntarily treat people, and he doesn't go on about how this was a life that could have been so much different if only she had been forced to have psychiatric care. I found the story to be a richer one told simply as it was without the moralizing.
So having said that, I am now going to invoke my role as an expert on involuntary treatment to talk about the plight of the "homeless mentally ill." Why the quotation marks? Well, first I'd like to differentiate those who are homeless from those I prefer to call 'street people.' You are homeless if you are an adult without a stable residence, and most people who are homeless are not sleeping on the streets. They may be in shelters, in motels or the single room occupancies, or staying in the guestroom or on the couch of a friend or relative. Those who are actually sleeping on the streets are our society's sickest and most disenfranchised members. The quotations also serve to remind me that "the mentally ill" is not a term I like to use: these are people with psychiatric disorders, not to be defined by those disorders. While many like to talk about the plight of the homeless mentally ill, I'd like to suggest that as a society, we should invest our resources in helping all of our countrymen who sleep on the streets, whether they are mentally ill, addicted, or simply indigent.
In a wealthy country such as we are, the fact that there are people who spend their nights on the street should be a source of shame to all of us. Logically, this can't be about money: there is nothing cheap about leaving people on the street-- to start with, they have high medical expenses, and high incarceration rates. One way or another, they cost us all money. Personally, I don't believe it should be legal to sleep in public places, and as a society, we should feel obligated to provide sick and destitute people with more than a nighttime cot in a room with other people where they may not be safe.
If you've followed my Shrink Rap posts, or read our book, Committed: The Battle Over Involuntary Psychiatric Care, then you know that the issues of involuntary treatment are nuanced and complex, and that I think it should be avoided when possible as there is the risk that involuntary care leaves some people feeling traumatized and angry, and because we all cherish the right to make our own medical decisions. You also may know that I'm not much for invoking "anosognosia" as a reason to force people to have treatment, and do see my post on this over on Psychology Today. But you may also know that I believe there are times when there really seems to be no choice but to force treatment, and when it is simply the right thing to do to keep everyone safe. A traumatized patient is better than a dead patient.
So what about Nakesha Williams, and others like her who are "dying with their rights on." I messaged Mr. Weiser, the NY Times journalist, and asked him if she had ever been treated. In the article he talks with friends who have tried to get her help, and with case workers from a mental health agency who tried to engage her, all of which she refused. Mr. Weiser thought Nakesha had been in treatment briefly when she was younger--he didn't know for sure if she had ever taken medications-- but it does not appear that she had any treatment in the years she lived on the streets of New York City. Her family had long before lost contact with her.
So Mr. Weiser didn't say it, but I will: if people suffering from psychosis are living on the streets, unprotected from the elements, at risk of illness or of being prey to criminals, and they are so ill that they are refusing offers of housing, healthcare, and help getting financial entitlements, then they should be hospitalized and treated against their will. As traumatic as forced care can be, I believe it is preferable to the obvious risks people on living on the streets face each and every day, and would offer them a chance at a safer and more productive, less tormented existence. Ms. Williams was certainly a risk to herself, and her story is one of society's shame.
So do we need new laws to get Ms. Williams and those in her situation care? I don't believe we do: she was a risk, as can be seen by her untimely death, and as I've said above, I don't think it is a person's right (or it shouldn't be) to live in public places. Would treatment -- and in this case, I specifically mean antipsychotic medications-- have changed her life? I don't know, but I would hope so.
There, I said it. Now please let me add a plug for Housing First options that place people in housing without first requiring them to be free from drugs or alcohol, or to accept psychiatric care, as a condition of housing.
Posted by Dinah on Sunday, March 04, 2018
Thursday, March 01, 2018
It's been just about a month since I last posted here, and what a month it's been. I was away for a couple of weeks on a wonderful family vacation to Vietnam and Cambodia. While it was a mostly psychiatry-free trip, the sign above did grab my attention. It was a sign at the ecolodge where we were staying in Mai Chau, a rural area of Vietnam where water buffalo are still used as work animals in the rice paddies. Why are persons with mental illness not permitted in the pool? I have no idea, but it seems that stigma is rampant everywhere.
So do let me give links to the things I've been writing and thinking about.
~When I last posted on Shrink Rap, it was in response to Pete Earley's mention of 'the worried well.' Pete also ran my response and John Snook of the Treatment Advocacy Center wrote Pete a separate letter which he put up as it's own post. By all means, do join in the fuss over on Pete's Facebook page where he entertains comments.
~I moved venues and put up a somewhat related post on PsychologyToday called The Perplexing Semantics of Anosognosia: Why An Obvious Phenomena Has Sparked Controvery. See what you think, and I look forward to your comments.
~Over on Clinical Psychiatry News, I've written two articles on everyone's favorite topic: Medication Prices. In the first article, I did some comparison shopping for Abilify (aripiprazole) and Provigil (modafanil) and found that the prices varied by HUNDREDS of DOLLARS (and yes, I did mean to yell) per month, depending on the drug store. In the Second article, I interviewed GoodRx.com co-founder Doug Hirsch and learned about how drug prices are set and why GoodRx is able to offer deep discounts.
Finally, I'd like to send you over to today's New England Journal of Medicine to read a powerful article about a surgeon who was involuntarily treated for a suicidal major depression.
Posted by Dinah on Thursday, March 01, 2018
Thursday, February 01, 2018
Insurers, Not Legislators, are the Gatekeepers to Care, and a Call to Deep Six the Term "Worried Well."
Over on Pete Earley's blog, there is a post titled:
Pete is on the Interdepartmental Serious Mental Illness Coordinating Committee, a group operating under the Department of Health and Human Services. He is an extraordinary writer and a tremendous mental health advocate. His post inspired me to rant at him (Me rant? Shocking, I know...) and Pete and I are both posting my response. I can't begin to capture the essence of his post on the controversy over the NREPP website, nor will you need to understand that to read my response, but please read about it at the link above.
Thank you for your latest blog post on the work Dr. McCance-Katz is doing and thank you, again, for serving on the ISMICC. Let me start by saying that after 25+ years as a psychiatrist, I've never heard of the NREPP website, so I'm not certain whether it's it is a good thing or a bad thing that the website is now down. Instead, I'd like to respond to some of the things that were said in the course of your blog post.
You used the term "worried well." Please don't use that term, ever. It implies that there are people with legitimate suffering because they have "real" mental illnesses, and those whose suffering is trivial because they don't have "serious" mental illness. Suffering is suffering-- it all hurts, and sometimes those with no obvious signs of mental illness surprise us all when something suddenly goes horribly wrong. Psychiatric care is expensive, poorly reimbursed, time consuming, and stigmatized; people don't present for treatment for trivial reasons. There is the implication that some people are more deserving of care in a way we would never dream of bifurcating in any other field. Could you imagine if you went to the ER with chest pain and were derided because it turned out you had heartburn or a pulled muscle and were not having a heart attack? As doctors, we help people who are in distress, we don't make the distinction about whose suffering is valid and worthy of treatment.
I am all in favor of giving more resources to people with chronic and disabling mental illnesses -- these are society's most disenfranchised members, their suffering and the suffering of their families is immense, and they use our resources one way or another. If not through appointments with psychiatrists and the cost of their medications, then through lost productivity, the cost for medical care incurred from unhealthy life styles, and the cost of institutionalization. What I find difficult about these discussions is that psychiatry is the only arena where advocates ask for money for one set of patients at the expense of another. We don't ever suggest that money to treat metastatic lung cancer should come from denying treatment to those with basal cell carcinomas.
While I have you here, I'd like to bring up a related topic that perhaps you can get the ISMICC committee to look at, one that all of us might be able to agree on. When the topic turns to serious mental illness, the loudest and most controversial agenda is about legislation to make it easier to involuntarily hospitalize patients. While there are cases where this is an issue, for those of us in practice, there is a bigger issue: the real gatekeeper to getting very sick people adequate and optimal care is not the law, the gate keeper is the insurance/mangled care industry. Insurers have a erected a barrier to inpatient treatment which has set the standard for admission as "imminent danger." There are times when everyone can agree that a patient needs to be in the hospital: the patient, the family, the doctor, but if that patient does not present as being dangerous, it has become nearly impossible to get him or her into a hospital bed. This has trickled into our standard of care: psychiatrists no longer try to hospitalize patients who are not dangerous (usually suicidal) because they believe an insurance company will not authorize the the admission, that an ER will release the patient.
So the few available beds fill with admissions from the ER of people who are so depressed or so psychotic as to be dangerous, and elective admissions just don't end up happening. What does happen is that the few available inpatient beds get taken by very ill, very dangerous patients and the acuity level on inpatient units is very high. They often require security officers, and the environment is anything but healing; in fact, inpatient units have a high rate of assaults for both the patients and the staff. And then we wonder why people won't voluntarily admit themselves to these units when they are sick. This is the point where people in favor of easier standards to involuntarily admit patients shut me down: they say the patients have anosognosia, they don't know they are sick and they won't get care no matter what, and issues of safe, healing environments or medications that don't cause awful side effects are irrelevant. I beg to differ with that argument, and still contend that if psychiatric care was kinder, better funded, more palatable, and not stigmatized, then more of those who are not aware they are ill could be swayed to get care.
Psychiatry is the only medical specialty where the standard for admission has become life-threatening illness, not just being really sick.
It would be so helpful to all of us if there were more beds available and if insurance companies were not allowed to deny admission to very sick people because there was not an imminent threat of death. I do believe that is something that everyone in all the tents can agree on, and it's a good starting gate for all of us.
Posted by Dinah on Thursday, February 01, 2018
Tuesday, January 09, 2018
One Doctor's Struggles With Depression, Addiction, and Recovery: Finding Hope in An Intolerant Profession
Psychiatric News is running a series on Physician Burnout, part of an initiative by APA President Dr. Anita Everett. They asked me to write about medical licensing for the series, and in the course of writing the article, I spent a while talking to Dr. Luther Philaya, an Emergency Room doc who lost his license for his addiction to alcohol and opiates. Dr. Philaya sought help and things did not go smoothly. Instead of writing about licensing, I ended up writing about Luther, and I'll invite you to read, "System Changes Needed to Support Physician Seeking Help."
Dr. Philaya had more to say about the stigma of being a physician in recovery and wrote his own Op-ed piece for the Star Tribune. Reprinted below, with his permission
Recovery from addiction doesn't get the community support it needs
It's no small achievement, but, surprisingly, it's greeted as an ongoing social stigma.
By Luther Paul Philaya
January 8, 2018
In the fall of 2012, I entered treatment for addiction as a broken physician and man. Opioids were one of my drugs of choice, as they are for so many in today’s society. After weeks of intensive therapy, I was able to let go of the demons that had haunted me for decades, ones that I had medicated away with drugs and alcohol. More than 100 days later, I left the treatment facility with a renewed vigor for life — physically, mentally, emotionally and spiritually. I was eager to return to my medical practice with a completely different perspective, including a heightened sense of compassion and empathy for patients struggling with mental illness and addiction.
I looked forward to being welcomed back at my place of work as well as in my community. As with a cancer patient enduring grueling treatment and receiving compassion and empathy from family, friends and co-workers, surely there would be those eager to help with my transition. Maybe a casserole or two would be waiting, or a few get-well cards. Without a doubt, my workplace would help with my reintegration back into practice.
Sadly, I quickly realized that recovery from substance-use disorder is not celebrated by those outside of the recovery community. To the contrary, recovery — like active addiction — is stigmatized in our society. Rather than welcoming me back, I became a pariah among my co-workers of 22 years. Former friends were, for the most part, gone. What support there was came from the recovery community, but even there I fought shame. I learned to quickly — quietly and with furtive glances — enter and exit church basements or recovery clubs.
“Anonymous” became my mantra. The guilt and shame I experienced while in active addiction were there to welcome me into the recovery world as well. I began meetings by proclaiming, “Hi, I’m Luther and I’m an addict. I’m powerless over my addiction.” I learned to fear that I was one small step away from relapse.
Recovery organizations such as AA have done incredible things in the battle against substance-use disorder. I have benefited from their program. But as a person in recovery, now that I have a clear mind, I believe I’m quite powerful against returning to my addiction as long as I maintain a disciplined recovery lifestyle. My rational brain is able to make the choice not to return to that life. Being reminded that I am an addict only perpetuates my shame, while trapping me in a toxic thought process, including ongoing shame about my own recovery.
A while back, I decided that I couldn’t survive my own recovery this way. I am proud of that decision; it is the crux of all aspects of my health. I’m done hiding my recovery. I will let the public know I’m not ashamed.
I admire the tenacity and persistence of those involved in changing the public stigmatization toward the AIDS epidemic. Through hard work by activists, the public perception of HIV as a gay man’s disease brought on by poor moral choices has changed. Where once HIV was feared and the sufferers stigmatized, it has become one of the many diseases that afflict humankind. Today, HIV sufferers no longer need to hide in closets of shame.
Recovery needs to be treated in a similar manner. There are movements afloat that celebrate recovery. The message is getting out that recovery need not be shameful. But the public needs to embrace those on this journey as well. Communities, not just recovery organizations, need to become recovery-friendly.
Imagine a sign reading: “Welcome to Minnesotaville, a recovery-friendly community” or “Welcome to our coffee shop, a recovery-friendly establishment.” Imagine a bumper sticker that reads: “Proud parent of a child in recovery.” Imagine communities making recovery fashionable, trendy and celebrated. Rather than wringing our hands over the depth and breadth of the current drug epidemic, communities can offer warm, welcoming environments.
I’ve changed my perspective. Rather than proclaiming that I’m an addict, I will proudly introduce myself as “a person in long-term recovery, which means I haven’t had a drink or used a drug since Oct. 11, 2012.”
Now that’s recovery.
Luther Paul Philaya, of Woodbury, is a physician.
Posted by Dinah on Tuesday, January 09, 2018