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Friday, November 18, 2016

Presidential Election 2016 and the internet--the real winner

The last year has been difficult to watch, and the last few months even more so. News and quasi-news organizations have been bombarding my email with stories about the people vying for our presidency. It has been anywhere from difficult to completely impossible to screen this information for accuracy. Lies and information taken out of context and repeated until it seems true has been part of both party's rhetoric. The whole field of potential candidates were infected with it before the primary elections.

The emotions have been high, too. By the time the election finally happened on November 8th, we had a comic book villain straight out of the Batman movies running against Satan in female form. The outcome has left people deeply sad and frightened, even people who voted for the winner. There is hope, too, and kindness and gathering together. There is huge uncertainty.

I've been alive for 13 presidential elections, and this one was really different. This is partly because of an increasing gap between rich and poor, fallout of the financial crisis of 2008 and the changing international landscape, but the biggest change has been the growth of our use of the internet and social media.

Most people like to believe that the reason for our recent presidential election results can be found in the thoughts and behaviors of human beings. It feels good, in the face of a frightening and unexpected event to imagine a way that it could have been under our control, that next time we could anticipate it and make significant changes.

As human civilization has evolved, so has our ability to communicate complex ideas. Language, then writing, then printing presses, then telegraph, radio, television and now the internet, links us and allows us to learn from each other and share ideas and feelings and events. With the internet, and now our mobile phones which are ridiculously powerful computers in our pockets, we nearly share a common brain. Even the progressively smaller portion of the population that isn't directly connected via a computer is indirectly connected if they read a newspaper, watch a TV or even talk to a neighbor.

The internet of news is a small part of the entity that is the entire internet. Items that people like to look at rise to the top of any search and appear prominently on Facebook or other sites where people share information. This could be a cute baby dancing, a way to lose weight or a delicious news story, such as a powerful person behaving poorly and getting caught. We will choose to look at these things even if they are out of context, don't work or aren't true, and they will become a larger proportion of what we see. We will be less likely to look at things that are complex, nuanced, and present more than one side of an issue. What we click on is what we get.

There is actually quite a market in made to order "news". Paul Horner was featured in the Washington Post, explaining that the lies he successfully spread via Facebook and other sites around the elections were really just satire and made to be taken as such. But readers believed that people were being recruited and paid $3500 to protest at Donald Trump rallies (he invented this and even created a fake Craigslist advertisement to back it up.) He made money on stories like this, and others such as that the Amish had decided to vote for Trump. Ads on these fake news sites make a good salary for a person with a good imagination. I won't link the stories because that would, in a small way, add to the viral nature of the stories and Paul Horner's livelihood. In fact, by posting a link to the Washington Post article, which links to Paul Horner's stories and his ads, I have contributed to his success, and perhaps the success of fake news in creating misguided popular sentiment.

Humans are amazing. We have created a way to communicate instantly with a group of friends on opposite sides of the earth. But with this we have power to make fiction nearly real, with potentially disastrous consequences. On the medical side of things, I have noticed that the ability to be completely absorbed in communication that requires nothing but small movements of the hands has contributed to an epidemic of diabetes and obesity. Although entertainment that doesn't require the use of resources may be an important aspect of life in a resource stressed world, I don't think we are ready for what we have created. We are more than what we have let ourselves become. We have abilities to connect via touch and smell and eye contact. We care for each other deeply. We have let ourselves become communication nodes made of flesh in a supercomputer which does not have our best interests in mind.

Personally I am being a bit childish about all of this. The internet has let me down. It has sucked up my free time and made my patients fat and has elected people to the country's highest office based at least significantly on information which is not true. I read that we need to take to social media to unite to fight for causes I believe in, and I am questioning that. Facebook is no longer on my phone. I think several times before clicking on links. And I realize that this is a piddly and ineffective response to a problem that is huge and unacceptable. There has been tremendous good that has come out of our ever more powerful abilities to communicate, but presently I am very angry at the internet and I refuse to play.

Monday, November 7, 2016

Suicide, psychiatric care and inadequate resources

An article released today in the JAMA sites evidence that the suicide rate in America has risen by 24% in the last 15 years associated with a significant reduction in the numbers of psychiatric beds available. The US has had a lower capacity for psychiatric patients than comparable countries in Europe for years, but in between 1998 and 2013 that number dropped even further.

Waiting in the ER for days
This trend has resulted in atrocious treatment for people with mental illness. Because it is so difficult to find room in a mental hospital for patients with mental conditions that make it unsafe for them to return home, such as suicidal thoughts or intentions, we sometimes see these people spend days or even weeks in emergency rooms just waiting for something to open up. I never saw this a decade ago, but now it is not uncommon, even in our small critical access hospital, to see a patient in one of the little windowless and noisy cubicles of our ER for days at a time. They can't move upstairs to a more comfortable, if inappropriate, hospital bed because our hospital cannot offer psychiatric hospitalization because we have no psychiatrist on staff. Psychiatrists are rare in small towns.

Many factors led up to this
This situation is a slow motion car wreck, not an all of a sudden sort of thing. Care for people with mental illness has been spotty and often terrible in the US, but has generally had a trajectory that aims toward better care and understanding. Early in the 19th century an approach called "institutionalization" created mental hospitals which were intended to care for people with what was then untreatable mental illness for long periods of time. These institutions fostered dependence, usually did not cure or treat psychiatric disorders, made patients vulnerable to abuse and, to top it all off, were quite expensive. Some of the costs were defrayed by unpaid work required of inmates, but in 1973 a court ruled that they were owed at least minimum wage, making the overcrowded and expensive institutions even less viable. Starting in the 1960's a strong movement, led by mental health pioneers, pushed for deinstitutionalization. It was argued that most mental patients could have their needs met by community mental health centers and could live in sheltered living situations such as halfway houses. Many state mental hospitals were closed in the 1970's and 1980's, with good and bad results. The number of severely mentally ill people who are homeless did increase significantly, putting a higher burden on already stressed acute care hospitals. Drug therapy for depression, bipolar disorder and schizophrenia began to be more effective, though, which meant that some people with these diseases genuinely got better and were able to be successfully independent.

Medical insurance and mental health
There was less capacity for inpatient care of mental patients after deinstitutionalization, but for many of these people any care at all was prohibitively expensive because most insurance plans had little or no coverage for mental health issues. In 1996 the Mental Health Parity Act was passed which required health insurance companies to cover mental health costs up to the same dollar amount as covered for medical or surgical care. Insurance companies quickly circumvented this by restricting numbers of visits and numbers of days in the hospital. In 2008, as the real estate market, banks and stock market were going up in flames, a rider was placed on TARP (Troubled Asset Relief Program--otherwise known as the bank bailout) called the Mental Health Parity and Addiction Equity Act. This was worded in such a way that mental health care is now generally covered by insurance.

It is wonderful that people with depression, schizophrenia, bipolar disorder and other serious mental illness can get help without necessarily bankrupting their families. This can mean that people get treatment for these problems before they get serious enough to require hospitalization. It probably also increases the demand for psychiatrists and psychiatric beds, both of which are in short supply.

The American psychiatrist: an endangered species
Psychiatry is not a very popular specialty. Out of about 30,000 residency positions each year, only 211 were for psychiatry in 2014-15. That would translate to 211 new psychiatrists for the whole US the year they complete training, assuming all of those candidates finish the program and choose to practice in the field. Many psychiatrists are aging and retiring and there is already a critical shortage of psychiatrists to meet our present needs. Psychiatry is one of the lower paid medical specialties and is a difficult row to hoe. Successful treatment of patients is very dependent on variables over which a psychiatrist has no control, such as community support, housing and job programs.

Prisons: our new insane asylums
Prisons now house a tremendous number of people with mental illness. In 2007 the Department of Justice reported that 24% of jail inmates had symptoms of psychosis, about a quarter of people in jails and prisons had a history of mental illness and a higher percentage had symptoms of mania and depression. The total number of patients in state mental hospitals is about 35,000 and the number or mentally ill people in prison is over 10 times that number. It is very difficult for people dealing with mental problems to tolerate the stresses of incarceration, leading to high rates of injury in fights and attempted suicide.

But people with mental disorders who are at risk for injuring others or breaking the law are more likely to get a bed in a psychiatric facility than people who are simply miserable or increasingly psychotic and have not broken the law, who could really benefit from a stay in a psychiatric hospital to stabilize their medication and give them intensive treatment. It is those miserable, suicidal and psychotic to the point of inability to care for themselves people who end up in emergency rooms for days awaiting a bed.

What would it be like...
I can only imagine how it feels to be seriously mentally ill in some of these situations. Picture being seriously depressed or anxious and being in prison, where kind words are mostly non-existent and there is nowhere to take comfort. Or schizophrenic, hearing voices that break you down, surrounded by nobody who cares. I can hardly allow myself to conceive of depression, anxiety or psychosis while homeless, exposed to the rain and the cold and vulnerable to assault. Closer to home are the patients who wait in the emergency rooms, with nothing to do, no chance to go outside, take a walk, lying on a 30 inch wide gurney covered with rumpled sheets, contemplating suicide while having no idea what is happening and when.

If we were to fix this, what steps would we need to take?

Clearly we need more psychiatrists. We also need more psychologists and they need more authority to treat, including with medications. This is a different conversation, with intrigue that I don't really understand. But we do need psychiatrists, MD trained, motivated, excellent at what they do, and we need to pay them in accordance with how vital their work is. There are already incentive programs to train as a psychiatrist and work in underserved areas, but we need more incentives.

We need more capacity to take care of patients in hospitals, for those times when things get too intense for them to survive independently.

We need systems to help take care of people with mental illness who need jobs and housing and treatment for substance abuse. We need to strengthen social networks in neighborhoods and communities. This is vitally important for keeping patients out of psychiatric hospitals and out of prison.

We need to shift people with mental illness out of the prisons, which are overcrowded, overused and dysfunctional. This will involve better and more capable staffing and better oversight along with more capacity to take care of them in psychiatric hospitals and community mental health facilities.

We need to support the families of these patients because they are often the only stable thing in their lives. Patients with mental illnesses often burn out their families which is a tragedy in so many ways. Programs to support families, including caregivers and assistants to help support patients' independence should be strengthened.

All of this will cost money, but I suspect not more money than we are presently spending on our dysfunctional systems. Shifting money towards appropriate care for people with mental health problems will not only reduce costs that go to warehousing many of them in the prison system and the cost of acute medical care for the homeless and those plagued with addiction, it might also decrease the overall national burden of misery, hopelessness and isolation.

Thursday, November 3, 2016

Recovering--a sacred time.

One day a few weeks ago, after returning from a set of seven 12 hour shifts in a hospital away from home, my husband convinced me to go to a concert. The group performing was the Deviant Septet, based out of Brooklyn, NY. They were an odd combination of instruments and they played mostly newly composed music.

The second piece in their program was by Chris Cerrone and was called "Recovering." I expected nothing, perhaps a nap even, but was completely absorbed by the music which wordlessly represented a magical period that I get to observe regularly but rarely remark upon.

Patients come in to the hospital when they are sick, and often getting sicker. They are vulnerable and place themselves in the hands of strangers. Usually they feel terrible. We do things to them to try to make them better. Often we are successful. And then something magical happens. Their faces look brighter. Their vital signs stabilize. Their eyes focus. They make jokes. It's still not over, though. There are setbacks. There is pain. They are weak and their appetites are not vigorous. But a gate has been passed through.

I don't often take the time to appreciate this transition. For me it is often filled with new concerns. What next? How can we all avoid this kind of event in the future? How much more time before this person can leave the hospital?

This piece of music took me back to the times when I was sick and finally getting better, when the world around me began to be relevant again, and sometimes beautiful. It reminded me that there is a thing that happens, this "recovering", and spending a little time noticing it will be a good practice.