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Burnout: A concept that rebrands mental illness for professionals
Over the past years, I have had the opportunity to attend countless lectures on burnout provided by colleagues spanning across many fields in mental health and health care in general. The talks generally follow a common narration: 1. Your work is important and meaningful to many. 2. Your work requires significant training, dedication, and passion. 3. While you get personal gratification from your work, it does come with a cost. 4. This cost can be great and can affect you physically and mentally. 5. This cost is called burnout.
Burnout is described as irritability (poor mood), low energy, poor concentration, difficulty appreciating enjoyable things (anhedonia), and poor sleep, among other symptoms, as a result of work stress. At this point in the lectures, I usually ask whomever is sitting next to me: “I came in late, is this a lecture on depression?” to which the answer is typically “No! Of course not, this is about ‘burnout’ not mental illness.” And here lies a concern about burnout: Is burnout a concept describing depression that we have repackaged to protect professionals from the stigmatization of mental illness? Does our tendency not to characterize patients’ struggles as burnout stigmatize them – and imply that their employment is not challenging to cause burnout?
According to the literature, a range of factors affects burnout in professionals: lack of control, unclear job expectations, dysfunctional workplace dynamics, extremes of activity, lack of social support, work-life imbalance. Contrary to depression, burnout is not caused by neurobiological problems. Patients with burnout don’t have chemical imbalances, hyperactive default mode networks, or overactive amygdalas. Burnout is caused by social factors and affects dedicated, caring, and exceptional individuals who have been pushed outside their window of tolerance.
Literature suggests a variety of remedies to treat burnout: Reevaluate your employment, discuss occupational concerns with your supervisor, discuss with colleagues, receive help from your social support system, and seek human resources services. In addition, experts recommend engaging in relaxing activities, improving your sleep hygiene, exercising regularly, and participating in mindfulness to reduce symptoms. Contrary to depression, burnout does not require individuals to fix their maladaptive thoughts or discover inadequate unconscious beliefs that may be affecting their work. Contrary to depression, burnout does not require the rebalancing of neurochemistry using psychotropic medication.
The concept of burnout engenders concerns. I fear that it divides physicians and patients into two different classes and thus further stigmatizes those with mental illness. It implies that we physicians are somehow immune from mental illness and its consequences. We do not suffer from brain abnormalities, we do not require mind-altering medications, we are not “mentally ill.” Contrarily, at times it might be implied that patients’ jobs are not important enough to cause burnout; if they feel sad, anhedonic, have poor energy and poor sleep, it is because they have mental illness. Their brains are inadequate and flawed. But for physicians, our brains are intact, just pushed beyond human capabilities.
I should point out that I do not think that burnout experts believe or desire to promote such concepts. I am not aware of burnout experts championing physician exceptionalism or promoting the stigmatization of patients. I believe that this problem is an unintended consequence, a side effect, of the idea of burnout itself.
Another concern I have is that the concept of burnout may actually hinder physicians from seeking necessary and appropriate professional services to address symptoms. Interestingly, most lectures I have attended on burnout have not discussed the concerning number of physicians who end their lives by suicide. There was a time when I argued against the removal of the grief exclusion in the DSM; I worried that we were pathologizing natural emotional reactions to trauma. However, I have come to realize that, if someone is debilitated by depression, seeking professional help should not be predicated on the trigger. As such, I would recommend the vast number of physicians who state burnout in surveys to seriously consider the possibility that they may, in fact, be suffering from mental illness. We encourage our patients to seek help and speak out against stigmatization; isn’t it time that we as professionals should not be afraid to do the same?
I have concerns about the concept of burnout, but I certainly do not think that we should get rid of the idea. On the contrary, I applaud this attempt at de-pathologizing, and de-medicalizing human suffering. As many have argued with more or less success and controversy of the years, many emotional problems are not best suited to be treated by psychotropic medication or even psychiatry. I think that psychiatry should embrace paradigms that include social and occupational constructs of emotional pain, not rooted in diseases and/or chemical imbalances. Such paradigms should, furthermore, not be limited to certain professions or life circumstances. We are all affected by human suffering. Access and willingness to appropriate care or support should not be granted only to those with a mental illness diagnosis.
Burnout is a promising idea that challenges our conceptualization of mental disorders. Burnout brings a humanity to emotional pain frequently lost in the medicalized diagnoses of the DSM. Psychiatry should seriously consider opening its door to nonmedicalized understanding of psychological suffering. By opening those doors, we begin to create a less medicalized construct for human suffering. We begin to create one based on shared human experience.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
Over the past years, I have had the opportunity to attend countless lectures on burnout provided by colleagues spanning across many fields in mental health and health care in general. The talks generally follow a common narration: 1. Your work is important and meaningful to many. 2. Your work requires significant training, dedication, and passion. 3. While you get personal gratification from your work, it does come with a cost. 4. This cost can be great and can affect you physically and mentally. 5. This cost is called burnout.
Burnout is described as irritability (poor mood), low energy, poor concentration, difficulty appreciating enjoyable things (anhedonia), and poor sleep, among other symptoms, as a result of work stress. At this point in the lectures, I usually ask whomever is sitting next to me: “I came in late, is this a lecture on depression?” to which the answer is typically “No! Of course not, this is about ‘burnout’ not mental illness.” And here lies a concern about burnout: Is burnout a concept describing depression that we have repackaged to protect professionals from the stigmatization of mental illness? Does our tendency not to characterize patients’ struggles as burnout stigmatize them – and imply that their employment is not challenging to cause burnout?
According to the literature, a range of factors affects burnout in professionals: lack of control, unclear job expectations, dysfunctional workplace dynamics, extremes of activity, lack of social support, work-life imbalance. Contrary to depression, burnout is not caused by neurobiological problems. Patients with burnout don’t have chemical imbalances, hyperactive default mode networks, or overactive amygdalas. Burnout is caused by social factors and affects dedicated, caring, and exceptional individuals who have been pushed outside their window of tolerance.
Literature suggests a variety of remedies to treat burnout: Reevaluate your employment, discuss occupational concerns with your supervisor, discuss with colleagues, receive help from your social support system, and seek human resources services. In addition, experts recommend engaging in relaxing activities, improving your sleep hygiene, exercising regularly, and participating in mindfulness to reduce symptoms. Contrary to depression, burnout does not require individuals to fix their maladaptive thoughts or discover inadequate unconscious beliefs that may be affecting their work. Contrary to depression, burnout does not require the rebalancing of neurochemistry using psychotropic medication.
The concept of burnout engenders concerns. I fear that it divides physicians and patients into two different classes and thus further stigmatizes those with mental illness. It implies that we physicians are somehow immune from mental illness and its consequences. We do not suffer from brain abnormalities, we do not require mind-altering medications, we are not “mentally ill.” Contrarily, at times it might be implied that patients’ jobs are not important enough to cause burnout; if they feel sad, anhedonic, have poor energy and poor sleep, it is because they have mental illness. Their brains are inadequate and flawed. But for physicians, our brains are intact, just pushed beyond human capabilities.
I should point out that I do not think that burnout experts believe or desire to promote such concepts. I am not aware of burnout experts championing physician exceptionalism or promoting the stigmatization of patients. I believe that this problem is an unintended consequence, a side effect, of the idea of burnout itself.
Another concern I have is that the concept of burnout may actually hinder physicians from seeking necessary and appropriate professional services to address symptoms. Interestingly, most lectures I have attended on burnout have not discussed the concerning number of physicians who end their lives by suicide. There was a time when I argued against the removal of the grief exclusion in the DSM; I worried that we were pathologizing natural emotional reactions to trauma. However, I have come to realize that, if someone is debilitated by depression, seeking professional help should not be predicated on the trigger. As such, I would recommend the vast number of physicians who state burnout in surveys to seriously consider the possibility that they may, in fact, be suffering from mental illness. We encourage our patients to seek help and speak out against stigmatization; isn’t it time that we as professionals should not be afraid to do the same?
I have concerns about the concept of burnout, but I certainly do not think that we should get rid of the idea. On the contrary, I applaud this attempt at de-pathologizing, and de-medicalizing human suffering. As many have argued with more or less success and controversy of the years, many emotional problems are not best suited to be treated by psychotropic medication or even psychiatry. I think that psychiatry should embrace paradigms that include social and occupational constructs of emotional pain, not rooted in diseases and/or chemical imbalances. Such paradigms should, furthermore, not be limited to certain professions or life circumstances. We are all affected by human suffering. Access and willingness to appropriate care or support should not be granted only to those with a mental illness diagnosis.
Burnout is a promising idea that challenges our conceptualization of mental disorders. Burnout brings a humanity to emotional pain frequently lost in the medicalized diagnoses of the DSM. Psychiatry should seriously consider opening its door to nonmedicalized understanding of psychological suffering. By opening those doors, we begin to create a less medicalized construct for human suffering. We begin to create one based on shared human experience.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
Over the past years, I have had the opportunity to attend countless lectures on burnout provided by colleagues spanning across many fields in mental health and health care in general. The talks generally follow a common narration: 1. Your work is important and meaningful to many. 2. Your work requires significant training, dedication, and passion. 3. While you get personal gratification from your work, it does come with a cost. 4. This cost can be great and can affect you physically and mentally. 5. This cost is called burnout.
Burnout is described as irritability (poor mood), low energy, poor concentration, difficulty appreciating enjoyable things (anhedonia), and poor sleep, among other symptoms, as a result of work stress. At this point in the lectures, I usually ask whomever is sitting next to me: “I came in late, is this a lecture on depression?” to which the answer is typically “No! Of course not, this is about ‘burnout’ not mental illness.” And here lies a concern about burnout: Is burnout a concept describing depression that we have repackaged to protect professionals from the stigmatization of mental illness? Does our tendency not to characterize patients’ struggles as burnout stigmatize them – and imply that their employment is not challenging to cause burnout?
According to the literature, a range of factors affects burnout in professionals: lack of control, unclear job expectations, dysfunctional workplace dynamics, extremes of activity, lack of social support, work-life imbalance. Contrary to depression, burnout is not caused by neurobiological problems. Patients with burnout don’t have chemical imbalances, hyperactive default mode networks, or overactive amygdalas. Burnout is caused by social factors and affects dedicated, caring, and exceptional individuals who have been pushed outside their window of tolerance.
Literature suggests a variety of remedies to treat burnout: Reevaluate your employment, discuss occupational concerns with your supervisor, discuss with colleagues, receive help from your social support system, and seek human resources services. In addition, experts recommend engaging in relaxing activities, improving your sleep hygiene, exercising regularly, and participating in mindfulness to reduce symptoms. Contrary to depression, burnout does not require individuals to fix their maladaptive thoughts or discover inadequate unconscious beliefs that may be affecting their work. Contrary to depression, burnout does not require the rebalancing of neurochemistry using psychotropic medication.
The concept of burnout engenders concerns. I fear that it divides physicians and patients into two different classes and thus further stigmatizes those with mental illness. It implies that we physicians are somehow immune from mental illness and its consequences. We do not suffer from brain abnormalities, we do not require mind-altering medications, we are not “mentally ill.” Contrarily, at times it might be implied that patients’ jobs are not important enough to cause burnout; if they feel sad, anhedonic, have poor energy and poor sleep, it is because they have mental illness. Their brains are inadequate and flawed. But for physicians, our brains are intact, just pushed beyond human capabilities.
I should point out that I do not think that burnout experts believe or desire to promote such concepts. I am not aware of burnout experts championing physician exceptionalism or promoting the stigmatization of patients. I believe that this problem is an unintended consequence, a side effect, of the idea of burnout itself.
Another concern I have is that the concept of burnout may actually hinder physicians from seeking necessary and appropriate professional services to address symptoms. Interestingly, most lectures I have attended on burnout have not discussed the concerning number of physicians who end their lives by suicide. There was a time when I argued against the removal of the grief exclusion in the DSM; I worried that we were pathologizing natural emotional reactions to trauma. However, I have come to realize that, if someone is debilitated by depression, seeking professional help should not be predicated on the trigger. As such, I would recommend the vast number of physicians who state burnout in surveys to seriously consider the possibility that they may, in fact, be suffering from mental illness. We encourage our patients to seek help and speak out against stigmatization; isn’t it time that we as professionals should not be afraid to do the same?
I have concerns about the concept of burnout, but I certainly do not think that we should get rid of the idea. On the contrary, I applaud this attempt at de-pathologizing, and de-medicalizing human suffering. As many have argued with more or less success and controversy of the years, many emotional problems are not best suited to be treated by psychotropic medication or even psychiatry. I think that psychiatry should embrace paradigms that include social and occupational constructs of emotional pain, not rooted in diseases and/or chemical imbalances. Such paradigms should, furthermore, not be limited to certain professions or life circumstances. We are all affected by human suffering. Access and willingness to appropriate care or support should not be granted only to those with a mental illness diagnosis.
Burnout is a promising idea that challenges our conceptualization of mental disorders. Burnout brings a humanity to emotional pain frequently lost in the medicalized diagnoses of the DSM. Psychiatry should seriously consider opening its door to nonmedicalized understanding of psychological suffering. By opening those doors, we begin to create a less medicalized construct for human suffering. We begin to create one based on shared human experience.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
Sequential intercept model is really a ‘no-intercept model’
Ultimately, psychiatrists must take responsibility for complex patients.
In legal settings, the “sequential intercept model” for targeting people involved in the criminal justice system with mental illness has been proposed as an improvement for the status quo.
The model intends to divert individuals with mental illnesses at any one of five described stages in their journey through the legal system. In the first stage, a patient may be provided enough care in the community to never enter the criminal system. If that works, the patient may be diverted by first responders out of the legal system and back into treatment. Sequentially, throughout the remaining stages, the patient can be diverted by an attorney, the court, a presentencing correctional facility, the sentencing judge, a postsentencing correctional facility, or probation. The model rightfully encourages anyone in the continuum of care to take ownership of a situation and intervene.
I applaud the model for encouraging all participants to intervene in changing the course of our most challenging patients. However, I am reminded of the complexity of large systems trying to change. In practice, what I have seen is a series of half-hearted recommendations: Emergency responders who consider their role finished after giving a patient the number of the suicide hotline, attorneys who are satisfied by giving their clients an outdated list of community mental health clinics, judges who interpret their recommendations for treatment as a fait accompli, and correctional facilities that release patients with an absurdly short supply of medications and the address of an emergency room. I worry that by creating a model encouraging all to participate, we have just absolved ones who make any effort, even if inadequate.
In some ways, the sequential intercept model has similarities with modern mental health treatment teams. In many settings, a treatment team includes a series of providers who are sequentially involved in the life of a patient. A team can include a psychiatrist for psychopharmacology; a neuropsychologist for psychological testing; a social worker for psychotherapeutic strategies; another social worker to assist in obtaining social assistance; an addiction counselor for substance use disorder; another psychiatrist who monitors the administration of a single medication, like ketamine; and a pharmacist who approves the medication regimen. That’s several providers for the treatment of one patient.
As a forensic psychiatrist, I am often asked to review treatment plans of other providers. I am asked to comment on the appropriate nature of a given treatment. Often, insurance companies want to review the continued need for treatment or whether any treatment is warranted at all. Sometimes, employers want to review a treatment plan to ensure the safety of their employees. At times, courts will ask for a review and expectations from treatment of a defendant to assist in sentencing determinations. However, I have not yet been asked by anyone if the amount of care a patient is obtaining is too fragmented and without any clear leadership.
In our endless pursuit of medicalization and standardization of mental health, we have, especially in large systems, created specialization silos for the care of our patients. Many, if not most psychiatrists, do not participate in any psychotherapy; social workers and psychologists do not prescribe (for the most part); many substance abuse counselors only address sobriety and not other primary mental illness factors; and pharmacists cannot diagnose nor are they trained in psychosocial approaches. In many ways, we have defined participants not by what they do, but what they don’t do.
One also can be saddened by the enormous logistical complexity imposed on patients required to make numerous appointments, which can deprive them of time for recovery. However, my bigger concern is that the multiplicity of providers also permits the dissolution of accountability. In my experience, those large teams have an ability to deflect responsibility in ways that are unmatched by any single provider who cannot rely on putting the fault on someone else.
Sadly and ironically, those two parallel paradigms of mental illness and criminal care impose those problems on each other by averting any attempt at interception, a “no-intercept model.” Mental health programs will deny clients involved in the criminal justice system for requiring too much treatment, too little treatment, for lack of availability of one of the necessary providers, for requiring substance use treatment, or simply for being part of the criminal justice system. Accordingly, the legal system will fail to accept recommendations by mental health providers that mental health treatment is not paramount at this time and that the defendant would be better served by addressing his criminogenic risk factors. In response, the multitude of participants in the legal system will point to the mental health system for all answers.
Contrary to many if not most problems, I do not think that the solution lies somewhere in the middle, as this would require the five stages of the legal system to compromise with the nine hypothetical participants of the mental health system. For our part, as psychiatrists, we must accept that we are ultimately responsible for all levels of care. As a field, we are also responsible for educating the public and the legal system of our role and limitations in providing care as well as being available for providing such care. Correspondingly, the legal system is responsible for putting an adequate effort into diverting patients and having or obtaining adequate understanding of available and appropriate care for their defendants.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
Ultimately, psychiatrists must take responsibility for complex patients.
Ultimately, psychiatrists must take responsibility for complex patients.
In legal settings, the “sequential intercept model” for targeting people involved in the criminal justice system with mental illness has been proposed as an improvement for the status quo.
The model intends to divert individuals with mental illnesses at any one of five described stages in their journey through the legal system. In the first stage, a patient may be provided enough care in the community to never enter the criminal system. If that works, the patient may be diverted by first responders out of the legal system and back into treatment. Sequentially, throughout the remaining stages, the patient can be diverted by an attorney, the court, a presentencing correctional facility, the sentencing judge, a postsentencing correctional facility, or probation. The model rightfully encourages anyone in the continuum of care to take ownership of a situation and intervene.
I applaud the model for encouraging all participants to intervene in changing the course of our most challenging patients. However, I am reminded of the complexity of large systems trying to change. In practice, what I have seen is a series of half-hearted recommendations: Emergency responders who consider their role finished after giving a patient the number of the suicide hotline, attorneys who are satisfied by giving their clients an outdated list of community mental health clinics, judges who interpret their recommendations for treatment as a fait accompli, and correctional facilities that release patients with an absurdly short supply of medications and the address of an emergency room. I worry that by creating a model encouraging all to participate, we have just absolved ones who make any effort, even if inadequate.
In some ways, the sequential intercept model has similarities with modern mental health treatment teams. In many settings, a treatment team includes a series of providers who are sequentially involved in the life of a patient. A team can include a psychiatrist for psychopharmacology; a neuropsychologist for psychological testing; a social worker for psychotherapeutic strategies; another social worker to assist in obtaining social assistance; an addiction counselor for substance use disorder; another psychiatrist who monitors the administration of a single medication, like ketamine; and a pharmacist who approves the medication regimen. That’s several providers for the treatment of one patient.
As a forensic psychiatrist, I am often asked to review treatment plans of other providers. I am asked to comment on the appropriate nature of a given treatment. Often, insurance companies want to review the continued need for treatment or whether any treatment is warranted at all. Sometimes, employers want to review a treatment plan to ensure the safety of their employees. At times, courts will ask for a review and expectations from treatment of a defendant to assist in sentencing determinations. However, I have not yet been asked by anyone if the amount of care a patient is obtaining is too fragmented and without any clear leadership.
In our endless pursuit of medicalization and standardization of mental health, we have, especially in large systems, created specialization silos for the care of our patients. Many, if not most psychiatrists, do not participate in any psychotherapy; social workers and psychologists do not prescribe (for the most part); many substance abuse counselors only address sobriety and not other primary mental illness factors; and pharmacists cannot diagnose nor are they trained in psychosocial approaches. In many ways, we have defined participants not by what they do, but what they don’t do.
One also can be saddened by the enormous logistical complexity imposed on patients required to make numerous appointments, which can deprive them of time for recovery. However, my bigger concern is that the multiplicity of providers also permits the dissolution of accountability. In my experience, those large teams have an ability to deflect responsibility in ways that are unmatched by any single provider who cannot rely on putting the fault on someone else.
Sadly and ironically, those two parallel paradigms of mental illness and criminal care impose those problems on each other by averting any attempt at interception, a “no-intercept model.” Mental health programs will deny clients involved in the criminal justice system for requiring too much treatment, too little treatment, for lack of availability of one of the necessary providers, for requiring substance use treatment, or simply for being part of the criminal justice system. Accordingly, the legal system will fail to accept recommendations by mental health providers that mental health treatment is not paramount at this time and that the defendant would be better served by addressing his criminogenic risk factors. In response, the multitude of participants in the legal system will point to the mental health system for all answers.
Contrary to many if not most problems, I do not think that the solution lies somewhere in the middle, as this would require the five stages of the legal system to compromise with the nine hypothetical participants of the mental health system. For our part, as psychiatrists, we must accept that we are ultimately responsible for all levels of care. As a field, we are also responsible for educating the public and the legal system of our role and limitations in providing care as well as being available for providing such care. Correspondingly, the legal system is responsible for putting an adequate effort into diverting patients and having or obtaining adequate understanding of available and appropriate care for their defendants.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
In legal settings, the “sequential intercept model” for targeting people involved in the criminal justice system with mental illness has been proposed as an improvement for the status quo.
The model intends to divert individuals with mental illnesses at any one of five described stages in their journey through the legal system. In the first stage, a patient may be provided enough care in the community to never enter the criminal system. If that works, the patient may be diverted by first responders out of the legal system and back into treatment. Sequentially, throughout the remaining stages, the patient can be diverted by an attorney, the court, a presentencing correctional facility, the sentencing judge, a postsentencing correctional facility, or probation. The model rightfully encourages anyone in the continuum of care to take ownership of a situation and intervene.
I applaud the model for encouraging all participants to intervene in changing the course of our most challenging patients. However, I am reminded of the complexity of large systems trying to change. In practice, what I have seen is a series of half-hearted recommendations: Emergency responders who consider their role finished after giving a patient the number of the suicide hotline, attorneys who are satisfied by giving their clients an outdated list of community mental health clinics, judges who interpret their recommendations for treatment as a fait accompli, and correctional facilities that release patients with an absurdly short supply of medications and the address of an emergency room. I worry that by creating a model encouraging all to participate, we have just absolved ones who make any effort, even if inadequate.
In some ways, the sequential intercept model has similarities with modern mental health treatment teams. In many settings, a treatment team includes a series of providers who are sequentially involved in the life of a patient. A team can include a psychiatrist for psychopharmacology; a neuropsychologist for psychological testing; a social worker for psychotherapeutic strategies; another social worker to assist in obtaining social assistance; an addiction counselor for substance use disorder; another psychiatrist who monitors the administration of a single medication, like ketamine; and a pharmacist who approves the medication regimen. That’s several providers for the treatment of one patient.
As a forensic psychiatrist, I am often asked to review treatment plans of other providers. I am asked to comment on the appropriate nature of a given treatment. Often, insurance companies want to review the continued need for treatment or whether any treatment is warranted at all. Sometimes, employers want to review a treatment plan to ensure the safety of their employees. At times, courts will ask for a review and expectations from treatment of a defendant to assist in sentencing determinations. However, I have not yet been asked by anyone if the amount of care a patient is obtaining is too fragmented and without any clear leadership.
In our endless pursuit of medicalization and standardization of mental health, we have, especially in large systems, created specialization silos for the care of our patients. Many, if not most psychiatrists, do not participate in any psychotherapy; social workers and psychologists do not prescribe (for the most part); many substance abuse counselors only address sobriety and not other primary mental illness factors; and pharmacists cannot diagnose nor are they trained in psychosocial approaches. In many ways, we have defined participants not by what they do, but what they don’t do.
One also can be saddened by the enormous logistical complexity imposed on patients required to make numerous appointments, which can deprive them of time for recovery. However, my bigger concern is that the multiplicity of providers also permits the dissolution of accountability. In my experience, those large teams have an ability to deflect responsibility in ways that are unmatched by any single provider who cannot rely on putting the fault on someone else.
Sadly and ironically, those two parallel paradigms of mental illness and criminal care impose those problems on each other by averting any attempt at interception, a “no-intercept model.” Mental health programs will deny clients involved in the criminal justice system for requiring too much treatment, too little treatment, for lack of availability of one of the necessary providers, for requiring substance use treatment, or simply for being part of the criminal justice system. Accordingly, the legal system will fail to accept recommendations by mental health providers that mental health treatment is not paramount at this time and that the defendant would be better served by addressing his criminogenic risk factors. In response, the multitude of participants in the legal system will point to the mental health system for all answers.
Contrary to many if not most problems, I do not think that the solution lies somewhere in the middle, as this would require the five stages of the legal system to compromise with the nine hypothetical participants of the mental health system. For our part, as psychiatrists, we must accept that we are ultimately responsible for all levels of care. As a field, we are also responsible for educating the public and the legal system of our role and limitations in providing care as well as being available for providing such care. Correspondingly, the legal system is responsible for putting an adequate effort into diverting patients and having or obtaining adequate understanding of available and appropriate care for their defendants.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
Conflicting psychiatric agendas in our polarized world
A series of case discussions recently engendered discord among colleagues of ours. The conflicts raised questions about systemic biases within our field and their possible ramifications.
The cases discussed, like many in psychiatry, involved patients with severely maladaptive coping skills who lived with punishing friends, had little rewarding purpose, and had dismissive or abusive families. The conflicts involved whether the treating psychiatrists should promote seemingly obvious life choices or whether those perspectives were based in socionormative stereotypes seeped in mistaken traditional values that do not account for the rich array of experiences our patients come from.
One such case involved a seemingly masochistic patient who repeatedly found herself in abusive relationships and whether the psychiatrist should consider criticizing her partner choices. Another case involved a severely suffering veteran who felt paralyzed at home and whether the psychiatrist should encourage employment to diminish isolation. Yet another case involved a suicidal transgender patient who was in despair when feeling little relief after receiving gender-conforming surgery and – whether the psychiatrist should or could discuss perspectives on gender.
Those cases have led to accusations of misunderstanding science on both sides – and questions about the political justifications and consequences of psychiatric recommendations.
The field of psychiatry is appropriately embarrassed by its former association to misogynistic, homophobic, and even racist schools of thought. However, we wonder whether our current attempts at penance are at times discouraging important discussions. In some cases, our lowest-functioning patients living on the fringe of society benefit the most from the stabilizing influences of family, employment, social institutions, or religious worship. This is especially true considering how much social isolation has become an increasing reality of modern life. As such, we worry when colleagues argue that the promotion of common values is inherently suspect.
This problem may be exemplified by the public attacks on Allan Josephson, MD. Dr. Josephson, a child psychiatrist at the University of Louisville (Ky.), contends that he was ostracized and later fired from his position for communicating at a Heritage Foundation forum on his concerns about current recommended treatments and approaches for gender dysphoria. It appears that, despite being a renowned and previously deeply respected expert in the field, his opinions on the subject now go beyond the acceptable discourse of psychiatry. It is not just that the establishment disagrees with him, he allegedly has gone beyond the acceptable bounds of professionalism.
This reaction is surprising from numerous perspectives. First, his opinions would have seemed mainstream to many only a few years ago. Second, there is no large body of scientific evidence that has been generated to confirm that he is promoting an unscientific perspective that should rightly get ostracized by the medical community – such as anti-vaccination. Actually, some evidence suggests that some medical approaches to gender dysphoria have not always ameliorated the distress found in some patients.
After reviewing the evidence on gender reassignment surgery a few years ago, the Centers for Medicare & Medicaid Services concluded: “Based on an extensive assessment of the clinical evidence as described above, there is not enough high-quality evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria and whether patients most likely to benefit from these types of surgical intervention can be identified prospectively.”
Whether such a diagnosis should exist at all in the DSM is a worthy topic of discussion with inclusive arguments on both sides. Pathologizing gender dysphoria is stigmatizing. At the same time, a diagnosis may permit one to receive assistance for a recognized condition. One may rightfully want to discuss the scientific merit of a diagnosis without the interference of arguments based on political or social ramifications of said diagnosis, despite their obvious existence and import.
One should be able to voice scientific opinions in a fair-minded, nonpolitically biased manner that is not designed to intimidate and harass dissenters. One should note that a debate about the appropriateness of having said diagnosis will bring up many philosophical and deeply uncomfortable questions. Those questions point out the apparent nosologic problems inherent in DSM methodology that are extraordinarily difficult to solve. If psychiatry chooses to produce or dismiss psychiatric diagnoses based on the inherent political inconvenience of said diagnoses, rather than their scientific and medical basis, the entire field will rightly be called into question.
One may deplore the static and at times oppressive nature of cultural biases. However, it should be noted that the ability to safely step outside the supportive structure of family, employment, and social and religious institution is itself a privilege, one in which some our patients do not have the luxury of engaging in.
It is not clear to us how we got to this juncture. Part of psychiatric and medical training does involve learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition may be exaggerated into a desire to solve the human condition without challenging patients’ fundamental need for a well-rounded biologic, psychological, and social recovery. It is also possible that our desire to promote utopian hopes for society has blinded us from accepting the idea that, for many of our lowest-functioning patients, fitting in and participating in society can be their best path to recovery.
Psychiatry attempts to define and alleviate the suffering that accompanies some behaviors. As such, psychiatry has always and will always address and confront behaviors that society may condemn. At times, psychiatrists will be in sync or clash with societal trends. Sometimes science will contradict societal wishes. And ultimately, psychiatrists will hopefully make decisions informed in biopsychosocial constructs that best suit the patient in front of them no matter what society may want. In a polarized environment, psychiatry should remind itself that we cannot always or ever fix society, and that maintaining reasonable cultural norms and societal stability – while avoiding the traps of superficial culture wars and utopian visions – is often the wisest path.
Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.
A series of case discussions recently engendered discord among colleagues of ours. The conflicts raised questions about systemic biases within our field and their possible ramifications.
The cases discussed, like many in psychiatry, involved patients with severely maladaptive coping skills who lived with punishing friends, had little rewarding purpose, and had dismissive or abusive families. The conflicts involved whether the treating psychiatrists should promote seemingly obvious life choices or whether those perspectives were based in socionormative stereotypes seeped in mistaken traditional values that do not account for the rich array of experiences our patients come from.
One such case involved a seemingly masochistic patient who repeatedly found herself in abusive relationships and whether the psychiatrist should consider criticizing her partner choices. Another case involved a severely suffering veteran who felt paralyzed at home and whether the psychiatrist should encourage employment to diminish isolation. Yet another case involved a suicidal transgender patient who was in despair when feeling little relief after receiving gender-conforming surgery and – whether the psychiatrist should or could discuss perspectives on gender.
Those cases have led to accusations of misunderstanding science on both sides – and questions about the political justifications and consequences of psychiatric recommendations.
The field of psychiatry is appropriately embarrassed by its former association to misogynistic, homophobic, and even racist schools of thought. However, we wonder whether our current attempts at penance are at times discouraging important discussions. In some cases, our lowest-functioning patients living on the fringe of society benefit the most from the stabilizing influences of family, employment, social institutions, or religious worship. This is especially true considering how much social isolation has become an increasing reality of modern life. As such, we worry when colleagues argue that the promotion of common values is inherently suspect.
This problem may be exemplified by the public attacks on Allan Josephson, MD. Dr. Josephson, a child psychiatrist at the University of Louisville (Ky.), contends that he was ostracized and later fired from his position for communicating at a Heritage Foundation forum on his concerns about current recommended treatments and approaches for gender dysphoria. It appears that, despite being a renowned and previously deeply respected expert in the field, his opinions on the subject now go beyond the acceptable discourse of psychiatry. It is not just that the establishment disagrees with him, he allegedly has gone beyond the acceptable bounds of professionalism.
This reaction is surprising from numerous perspectives. First, his opinions would have seemed mainstream to many only a few years ago. Second, there is no large body of scientific evidence that has been generated to confirm that he is promoting an unscientific perspective that should rightly get ostracized by the medical community – such as anti-vaccination. Actually, some evidence suggests that some medical approaches to gender dysphoria have not always ameliorated the distress found in some patients.
After reviewing the evidence on gender reassignment surgery a few years ago, the Centers for Medicare & Medicaid Services concluded: “Based on an extensive assessment of the clinical evidence as described above, there is not enough high-quality evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria and whether patients most likely to benefit from these types of surgical intervention can be identified prospectively.”
Whether such a diagnosis should exist at all in the DSM is a worthy topic of discussion with inclusive arguments on both sides. Pathologizing gender dysphoria is stigmatizing. At the same time, a diagnosis may permit one to receive assistance for a recognized condition. One may rightfully want to discuss the scientific merit of a diagnosis without the interference of arguments based on political or social ramifications of said diagnosis, despite their obvious existence and import.
One should be able to voice scientific opinions in a fair-minded, nonpolitically biased manner that is not designed to intimidate and harass dissenters. One should note that a debate about the appropriateness of having said diagnosis will bring up many philosophical and deeply uncomfortable questions. Those questions point out the apparent nosologic problems inherent in DSM methodology that are extraordinarily difficult to solve. If psychiatry chooses to produce or dismiss psychiatric diagnoses based on the inherent political inconvenience of said diagnoses, rather than their scientific and medical basis, the entire field will rightly be called into question.
One may deplore the static and at times oppressive nature of cultural biases. However, it should be noted that the ability to safely step outside the supportive structure of family, employment, and social and religious institution is itself a privilege, one in which some our patients do not have the luxury of engaging in.
It is not clear to us how we got to this juncture. Part of psychiatric and medical training does involve learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition may be exaggerated into a desire to solve the human condition without challenging patients’ fundamental need for a well-rounded biologic, psychological, and social recovery. It is also possible that our desire to promote utopian hopes for society has blinded us from accepting the idea that, for many of our lowest-functioning patients, fitting in and participating in society can be their best path to recovery.
Psychiatry attempts to define and alleviate the suffering that accompanies some behaviors. As such, psychiatry has always and will always address and confront behaviors that society may condemn. At times, psychiatrists will be in sync or clash with societal trends. Sometimes science will contradict societal wishes. And ultimately, psychiatrists will hopefully make decisions informed in biopsychosocial constructs that best suit the patient in front of them no matter what society may want. In a polarized environment, psychiatry should remind itself that we cannot always or ever fix society, and that maintaining reasonable cultural norms and societal stability – while avoiding the traps of superficial culture wars and utopian visions – is often the wisest path.
Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.
A series of case discussions recently engendered discord among colleagues of ours. The conflicts raised questions about systemic biases within our field and their possible ramifications.
The cases discussed, like many in psychiatry, involved patients with severely maladaptive coping skills who lived with punishing friends, had little rewarding purpose, and had dismissive or abusive families. The conflicts involved whether the treating psychiatrists should promote seemingly obvious life choices or whether those perspectives were based in socionormative stereotypes seeped in mistaken traditional values that do not account for the rich array of experiences our patients come from.
One such case involved a seemingly masochistic patient who repeatedly found herself in abusive relationships and whether the psychiatrist should consider criticizing her partner choices. Another case involved a severely suffering veteran who felt paralyzed at home and whether the psychiatrist should encourage employment to diminish isolation. Yet another case involved a suicidal transgender patient who was in despair when feeling little relief after receiving gender-conforming surgery and – whether the psychiatrist should or could discuss perspectives on gender.
Those cases have led to accusations of misunderstanding science on both sides – and questions about the political justifications and consequences of psychiatric recommendations.
The field of psychiatry is appropriately embarrassed by its former association to misogynistic, homophobic, and even racist schools of thought. However, we wonder whether our current attempts at penance are at times discouraging important discussions. In some cases, our lowest-functioning patients living on the fringe of society benefit the most from the stabilizing influences of family, employment, social institutions, or religious worship. This is especially true considering how much social isolation has become an increasing reality of modern life. As such, we worry when colleagues argue that the promotion of common values is inherently suspect.
This problem may be exemplified by the public attacks on Allan Josephson, MD. Dr. Josephson, a child psychiatrist at the University of Louisville (Ky.), contends that he was ostracized and later fired from his position for communicating at a Heritage Foundation forum on his concerns about current recommended treatments and approaches for gender dysphoria. It appears that, despite being a renowned and previously deeply respected expert in the field, his opinions on the subject now go beyond the acceptable discourse of psychiatry. It is not just that the establishment disagrees with him, he allegedly has gone beyond the acceptable bounds of professionalism.
This reaction is surprising from numerous perspectives. First, his opinions would have seemed mainstream to many only a few years ago. Second, there is no large body of scientific evidence that has been generated to confirm that he is promoting an unscientific perspective that should rightly get ostracized by the medical community – such as anti-vaccination. Actually, some evidence suggests that some medical approaches to gender dysphoria have not always ameliorated the distress found in some patients.
After reviewing the evidence on gender reassignment surgery a few years ago, the Centers for Medicare & Medicaid Services concluded: “Based on an extensive assessment of the clinical evidence as described above, there is not enough high-quality evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria and whether patients most likely to benefit from these types of surgical intervention can be identified prospectively.”
Whether such a diagnosis should exist at all in the DSM is a worthy topic of discussion with inclusive arguments on both sides. Pathologizing gender dysphoria is stigmatizing. At the same time, a diagnosis may permit one to receive assistance for a recognized condition. One may rightfully want to discuss the scientific merit of a diagnosis without the interference of arguments based on political or social ramifications of said diagnosis, despite their obvious existence and import.
One should be able to voice scientific opinions in a fair-minded, nonpolitically biased manner that is not designed to intimidate and harass dissenters. One should note that a debate about the appropriateness of having said diagnosis will bring up many philosophical and deeply uncomfortable questions. Those questions point out the apparent nosologic problems inherent in DSM methodology that are extraordinarily difficult to solve. If psychiatry chooses to produce or dismiss psychiatric diagnoses based on the inherent political inconvenience of said diagnoses, rather than their scientific and medical basis, the entire field will rightly be called into question.
One may deplore the static and at times oppressive nature of cultural biases. However, it should be noted that the ability to safely step outside the supportive structure of family, employment, and social and religious institution is itself a privilege, one in which some our patients do not have the luxury of engaging in.
It is not clear to us how we got to this juncture. Part of psychiatric and medical training does involve learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition may be exaggerated into a desire to solve the human condition without challenging patients’ fundamental need for a well-rounded biologic, psychological, and social recovery. It is also possible that our desire to promote utopian hopes for society has blinded us from accepting the idea that, for many of our lowest-functioning patients, fitting in and participating in society can be their best path to recovery.
Psychiatry attempts to define and alleviate the suffering that accompanies some behaviors. As such, psychiatry has always and will always address and confront behaviors that society may condemn. At times, psychiatrists will be in sync or clash with societal trends. Sometimes science will contradict societal wishes. And ultimately, psychiatrists will hopefully make decisions informed in biopsychosocial constructs that best suit the patient in front of them no matter what society may want. In a polarized environment, psychiatry should remind itself that we cannot always or ever fix society, and that maintaining reasonable cultural norms and societal stability – while avoiding the traps of superficial culture wars and utopian visions – is often the wisest path.
Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.
Criminals in the psychiatric ED
Despite popular belief, the absence of a strong link between mental illness and violence has been well studied and established. In summary, in a small subset of patients, mental illness provides a minor increase in the risk of committing violence.1
In part as a result of this research, police departments across the country have established programs and protocols to divert patients with mental illness out of the legal system and into mental hospitals. Instead of accepting the common refrain that mental illness is the explanation and best predictor of all atrocious behaviors, police departments have correctly referred patients with mental illness to mental hospitals. We commend those initiatives and encourage their adoption in all locales. Yet, to safeguard such programs, we would like to warn of a potential pitfall and offer possible remedies.
Having worked in both correctional and clinical settings, we are saddened by the similar nature of the work with respect to the management of mental illness. It should defy logic to assume the need for mental health care in our jails is in any way comparable to the one in mental hospitals. However, we have grown accustomed to seeing large numbers of our most vulnerable patients with severe mental illness accumulating in our jails and correctional facilities, which often are the largest employers of mental health clinicians. The reasons correctional institutions have become so reliant on psychiatric clinicians are vast and complex. Incarceration is tremendously destabilizing and can lead to the onset or relapse of mental illness – even in the most resilient patients. In addition, mental illness is undertreated in our communities yet inescapable in the confined settings of our jails. Furthermore, our mass incarceration problems have resulted in the most disenfranchised populations, including our patients with mental illness, becoming the targets of policies criminalizing poverty.2
To prevent furthering the process by which our correctional facilities have become the new asylums,3 law enforcement agencies have enacted a vast array of initiatives. Some include the placement of mental health staff within emergency response teams. Some include training police officers in how to talk to patients with mental illness as well as how to deescalate mental health crises. Most of the initiatives have one common goal: diverting patients with mental illness who are better treated in mental hospitals from going to jail. However, herein lies the problem: If mental illness is an explanation for only a small subset of criminal behavior, why is there a large need to divert patients with mental illness from jails to mental hospitals?
Over the past few years, psychiatrists in emergency departments have noted a concerning trend: an increase in referrals to mental hospitals by law enforcement for what appears to be a crime with only a vague or obscure link to mental illness. Most psychiatrists who regularly work in emergency departments will witness many examples. Some might be fairly benign: “They were going to arrest me for trespassing; I was yelling at a coffee shop. But when I told them that I had run out of meds, they brought me here instead.”
However, some stories are more chilling, including the case of an older male who had made threats while shooting his gun in the air and was brought to the emergency department because, as the police officer told us, “I think that he is just depressed; you guys can keep him safe till he is better.”
We applaud society’s desire to reduce the criminalization of mental illness. We think that psychiatry should be deeply involved in the attempts to resolve this problem. Furthermore, we are cognizant that the number of patients with mental illness unnecessarily imprisoned as a result of prosecutorial zealousness is a larger problem than criminals inappropriately brought to mental hospitals. However, we also are aware of the limitation of psychiatric hospitals in solving nonpsychiatric problems.
Recent studies have demonstrated the need to examine criminogenic needs before psychiatric ones when attempting to reduce recidivism in all offenders, including those with mental illnesses.4 The emphasis on addressing psychiatric needs over criminogenic ones is misguided and not based on evidence. Yet, we appreciate the complexity of those questions and of individual cases.
Substance use disorders are emblematic of this problem. Psychiatry has now communicated the position that substance use disorders are mental illness and not a moral failing. However, are the crimes committed by individuals with substance use disorders, whether in a state of intoxication or driven by the cycles of addiction, the blameless result of mental illness? The legal system struggles with this question, trying to determine when addiction-related crimes should be referred to a diversion program or treated as a straightforward criminal prosecution. Those who favor diversion for addiction can point out that many criminal acts are associated with mitigating factors that are no less valid than is addiction.
However, those mitigating factors, such as poverty, childhood deprivation, or a violence-infused sociological milieu, cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. As such, if those factors alone were considered, no diversion would be offered by the courts. There also can be unforeseen consequences to this bias for diversion or criminal prosecution. Violent outbursts are a recognized part of PTSD in veterans. Psychiatrists who work at Veterans Affairs can be faced with the diagnosis of PTSD being used as an excuse for violent behavior, which may, at some level be valid, but which can be dangerous in that labeling a patient with that diagnosis might lower the barriers to violent behavior by providing a ready-made explanation already internalized by the patient through unspoken, sociocultural norms.
With the awareness of the complex nature of the intersectionality of mental illness and criminality, we recommend improvements to current diversion programs. As diversion programs rightfully continue to expand across the country, we likely will see an increase in the number of referrals by police officers to our emergency departments. Some of the referrals will be considered “inappropriate” after thorough and thoughtful clinical evaluation by emergency psychiatrists. The inappropriateness might be secondary to an absence of active symptoms, an absence of correlation between the illness and the offense, or a more urgent criminogenic need.
When faced with someone who will not benefit from diversion to a psychiatric emergency department, psychiatrists should have the tools to revert the person back into the legal system. Those tools could come in many forms – law enforcement liaison, prosecution liaison, or simply the presence of officers who are mandated to wait for the approval of the clinician prior to dismissing legal charges. Whatever the solution might be for any particular locale, policy makers should not wait for adverse events to realize the potential pitfalls of the important work being done in developing our country’s diversion programs.
References
1. Swanson JW et al. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015 May;25(5):366-76.
2. Ehrenreich B. “How America criminalized poverty.” The Guardian. 2011 Aug 10.
3. Roth A. “Prisons are the new asylums.” The Atlantic. 2018 April.
4. Latessa EJ et al. “What works (and doesn’t) in reducing recidivism.” New York: Routledge, 2015.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.
Despite popular belief, the absence of a strong link between mental illness and violence has been well studied and established. In summary, in a small subset of patients, mental illness provides a minor increase in the risk of committing violence.1
In part as a result of this research, police departments across the country have established programs and protocols to divert patients with mental illness out of the legal system and into mental hospitals. Instead of accepting the common refrain that mental illness is the explanation and best predictor of all atrocious behaviors, police departments have correctly referred patients with mental illness to mental hospitals. We commend those initiatives and encourage their adoption in all locales. Yet, to safeguard such programs, we would like to warn of a potential pitfall and offer possible remedies.
Having worked in both correctional and clinical settings, we are saddened by the similar nature of the work with respect to the management of mental illness. It should defy logic to assume the need for mental health care in our jails is in any way comparable to the one in mental hospitals. However, we have grown accustomed to seeing large numbers of our most vulnerable patients with severe mental illness accumulating in our jails and correctional facilities, which often are the largest employers of mental health clinicians. The reasons correctional institutions have become so reliant on psychiatric clinicians are vast and complex. Incarceration is tremendously destabilizing and can lead to the onset or relapse of mental illness – even in the most resilient patients. In addition, mental illness is undertreated in our communities yet inescapable in the confined settings of our jails. Furthermore, our mass incarceration problems have resulted in the most disenfranchised populations, including our patients with mental illness, becoming the targets of policies criminalizing poverty.2
To prevent furthering the process by which our correctional facilities have become the new asylums,3 law enforcement agencies have enacted a vast array of initiatives. Some include the placement of mental health staff within emergency response teams. Some include training police officers in how to talk to patients with mental illness as well as how to deescalate mental health crises. Most of the initiatives have one common goal: diverting patients with mental illness who are better treated in mental hospitals from going to jail. However, herein lies the problem: If mental illness is an explanation for only a small subset of criminal behavior, why is there a large need to divert patients with mental illness from jails to mental hospitals?
Over the past few years, psychiatrists in emergency departments have noted a concerning trend: an increase in referrals to mental hospitals by law enforcement for what appears to be a crime with only a vague or obscure link to mental illness. Most psychiatrists who regularly work in emergency departments will witness many examples. Some might be fairly benign: “They were going to arrest me for trespassing; I was yelling at a coffee shop. But when I told them that I had run out of meds, they brought me here instead.”
However, some stories are more chilling, including the case of an older male who had made threats while shooting his gun in the air and was brought to the emergency department because, as the police officer told us, “I think that he is just depressed; you guys can keep him safe till he is better.”
We applaud society’s desire to reduce the criminalization of mental illness. We think that psychiatry should be deeply involved in the attempts to resolve this problem. Furthermore, we are cognizant that the number of patients with mental illness unnecessarily imprisoned as a result of prosecutorial zealousness is a larger problem than criminals inappropriately brought to mental hospitals. However, we also are aware of the limitation of psychiatric hospitals in solving nonpsychiatric problems.
Recent studies have demonstrated the need to examine criminogenic needs before psychiatric ones when attempting to reduce recidivism in all offenders, including those with mental illnesses.4 The emphasis on addressing psychiatric needs over criminogenic ones is misguided and not based on evidence. Yet, we appreciate the complexity of those questions and of individual cases.
Substance use disorders are emblematic of this problem. Psychiatry has now communicated the position that substance use disorders are mental illness and not a moral failing. However, are the crimes committed by individuals with substance use disorders, whether in a state of intoxication or driven by the cycles of addiction, the blameless result of mental illness? The legal system struggles with this question, trying to determine when addiction-related crimes should be referred to a diversion program or treated as a straightforward criminal prosecution. Those who favor diversion for addiction can point out that many criminal acts are associated with mitigating factors that are no less valid than is addiction.
However, those mitigating factors, such as poverty, childhood deprivation, or a violence-infused sociological milieu, cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. As such, if those factors alone were considered, no diversion would be offered by the courts. There also can be unforeseen consequences to this bias for diversion or criminal prosecution. Violent outbursts are a recognized part of PTSD in veterans. Psychiatrists who work at Veterans Affairs can be faced with the diagnosis of PTSD being used as an excuse for violent behavior, which may, at some level be valid, but which can be dangerous in that labeling a patient with that diagnosis might lower the barriers to violent behavior by providing a ready-made explanation already internalized by the patient through unspoken, sociocultural norms.
With the awareness of the complex nature of the intersectionality of mental illness and criminality, we recommend improvements to current diversion programs. As diversion programs rightfully continue to expand across the country, we likely will see an increase in the number of referrals by police officers to our emergency departments. Some of the referrals will be considered “inappropriate” after thorough and thoughtful clinical evaluation by emergency psychiatrists. The inappropriateness might be secondary to an absence of active symptoms, an absence of correlation between the illness and the offense, or a more urgent criminogenic need.
When faced with someone who will not benefit from diversion to a psychiatric emergency department, psychiatrists should have the tools to revert the person back into the legal system. Those tools could come in many forms – law enforcement liaison, prosecution liaison, or simply the presence of officers who are mandated to wait for the approval of the clinician prior to dismissing legal charges. Whatever the solution might be for any particular locale, policy makers should not wait for adverse events to realize the potential pitfalls of the important work being done in developing our country’s diversion programs.
References
1. Swanson JW et al. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015 May;25(5):366-76.
2. Ehrenreich B. “How America criminalized poverty.” The Guardian. 2011 Aug 10.
3. Roth A. “Prisons are the new asylums.” The Atlantic. 2018 April.
4. Latessa EJ et al. “What works (and doesn’t) in reducing recidivism.” New York: Routledge, 2015.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.
Despite popular belief, the absence of a strong link between mental illness and violence has been well studied and established. In summary, in a small subset of patients, mental illness provides a minor increase in the risk of committing violence.1
In part as a result of this research, police departments across the country have established programs and protocols to divert patients with mental illness out of the legal system and into mental hospitals. Instead of accepting the common refrain that mental illness is the explanation and best predictor of all atrocious behaviors, police departments have correctly referred patients with mental illness to mental hospitals. We commend those initiatives and encourage their adoption in all locales. Yet, to safeguard such programs, we would like to warn of a potential pitfall and offer possible remedies.
Having worked in both correctional and clinical settings, we are saddened by the similar nature of the work with respect to the management of mental illness. It should defy logic to assume the need for mental health care in our jails is in any way comparable to the one in mental hospitals. However, we have grown accustomed to seeing large numbers of our most vulnerable patients with severe mental illness accumulating in our jails and correctional facilities, which often are the largest employers of mental health clinicians. The reasons correctional institutions have become so reliant on psychiatric clinicians are vast and complex. Incarceration is tremendously destabilizing and can lead to the onset or relapse of mental illness – even in the most resilient patients. In addition, mental illness is undertreated in our communities yet inescapable in the confined settings of our jails. Furthermore, our mass incarceration problems have resulted in the most disenfranchised populations, including our patients with mental illness, becoming the targets of policies criminalizing poverty.2
To prevent furthering the process by which our correctional facilities have become the new asylums,3 law enforcement agencies have enacted a vast array of initiatives. Some include the placement of mental health staff within emergency response teams. Some include training police officers in how to talk to patients with mental illness as well as how to deescalate mental health crises. Most of the initiatives have one common goal: diverting patients with mental illness who are better treated in mental hospitals from going to jail. However, herein lies the problem: If mental illness is an explanation for only a small subset of criminal behavior, why is there a large need to divert patients with mental illness from jails to mental hospitals?
Over the past few years, psychiatrists in emergency departments have noted a concerning trend: an increase in referrals to mental hospitals by law enforcement for what appears to be a crime with only a vague or obscure link to mental illness. Most psychiatrists who regularly work in emergency departments will witness many examples. Some might be fairly benign: “They were going to arrest me for trespassing; I was yelling at a coffee shop. But when I told them that I had run out of meds, they brought me here instead.”
However, some stories are more chilling, including the case of an older male who had made threats while shooting his gun in the air and was brought to the emergency department because, as the police officer told us, “I think that he is just depressed; you guys can keep him safe till he is better.”
We applaud society’s desire to reduce the criminalization of mental illness. We think that psychiatry should be deeply involved in the attempts to resolve this problem. Furthermore, we are cognizant that the number of patients with mental illness unnecessarily imprisoned as a result of prosecutorial zealousness is a larger problem than criminals inappropriately brought to mental hospitals. However, we also are aware of the limitation of psychiatric hospitals in solving nonpsychiatric problems.
Recent studies have demonstrated the need to examine criminogenic needs before psychiatric ones when attempting to reduce recidivism in all offenders, including those with mental illnesses.4 The emphasis on addressing psychiatric needs over criminogenic ones is misguided and not based on evidence. Yet, we appreciate the complexity of those questions and of individual cases.
Substance use disorders are emblematic of this problem. Psychiatry has now communicated the position that substance use disorders are mental illness and not a moral failing. However, are the crimes committed by individuals with substance use disorders, whether in a state of intoxication or driven by the cycles of addiction, the blameless result of mental illness? The legal system struggles with this question, trying to determine when addiction-related crimes should be referred to a diversion program or treated as a straightforward criminal prosecution. Those who favor diversion for addiction can point out that many criminal acts are associated with mitigating factors that are no less valid than is addiction.
However, those mitigating factors, such as poverty, childhood deprivation, or a violence-infused sociological milieu, cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. As such, if those factors alone were considered, no diversion would be offered by the courts. There also can be unforeseen consequences to this bias for diversion or criminal prosecution. Violent outbursts are a recognized part of PTSD in veterans. Psychiatrists who work at Veterans Affairs can be faced with the diagnosis of PTSD being used as an excuse for violent behavior, which may, at some level be valid, but which can be dangerous in that labeling a patient with that diagnosis might lower the barriers to violent behavior by providing a ready-made explanation already internalized by the patient through unspoken, sociocultural norms.
With the awareness of the complex nature of the intersectionality of mental illness and criminality, we recommend improvements to current diversion programs. As diversion programs rightfully continue to expand across the country, we likely will see an increase in the number of referrals by police officers to our emergency departments. Some of the referrals will be considered “inappropriate” after thorough and thoughtful clinical evaluation by emergency psychiatrists. The inappropriateness might be secondary to an absence of active symptoms, an absence of correlation between the illness and the offense, or a more urgent criminogenic need.
When faced with someone who will not benefit from diversion to a psychiatric emergency department, psychiatrists should have the tools to revert the person back into the legal system. Those tools could come in many forms – law enforcement liaison, prosecution liaison, or simply the presence of officers who are mandated to wait for the approval of the clinician prior to dismissing legal charges. Whatever the solution might be for any particular locale, policy makers should not wait for adverse events to realize the potential pitfalls of the important work being done in developing our country’s diversion programs.
References
1. Swanson JW et al. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015 May;25(5):366-76.
2. Ehrenreich B. “How America criminalized poverty.” The Guardian. 2011 Aug 10.
3. Roth A. “Prisons are the new asylums.” The Atlantic. 2018 April.
4. Latessa EJ et al. “What works (and doesn’t) in reducing recidivism.” New York: Routledge, 2015.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.
Why we need another article on suicide contracts
Every guideline and lecture on suicide risk assessment includes the message: “Do not use suicide contracts.” Yet, as forensic psychiatrists, we continue to see medical records that rely solely on the patient verbalizing, agreeing, or signing that they will be safe, in order to justify medical decision-making. A recent case we reviewed involving a grossly psychotic male spotlighted the meaninglessness of suicide contracts. In an attempt to understand the impulse by clinicians to use suicide contracts, we decided to review the topic.
Suicide risk assessment is a confusing and poorly explained skill in our field. Suicide risk assessment tools are well-intended. They are meant to identify and stratify risk, and help guide medical decision-making. Popular tools are startlingly different. How can two scales represent adequate psychiatric knowledge yet be completely different? SADPERSONS1 is widely used and still considered standard of care yet has nothing in common with the Columbia–Suicide Severity Rating Scale (CSSRS).2
For those of us working in forensic settings, we are aghast that neither assessment is modified for use in correctional settings or accounts for essential risk factors of suicide in jails and prisons (placement in solitary, significant charges, homeless, etc.) Yet, they are widely used in jails and prisons across the country. This can be extrapolated to all of us who work with specific populations yet are asked to follow generic scales by administrators.
In reviewing the literature, we are surprised to see the lack of acknowledgment that many tools used in suicide risk assessment have little to no evidence. Despite their numerous appearances in medical records that we review, we are not aware of existing evidence for asking patients whether patients are suicidal on an hourly basis, for psychotropic treatment other than lithium and clozapine (Clozaril), and for safety plans that involve telling the patient to call 911. Of even greater concern, suicide risk assessments themselves may have limited value because of a lack of evidence as suggested by large study findings. It may surprise some to learn that the National Institute for Health and Care Excellence (NICE) in the United Kingdom includes the following statement in its guidelines: “Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.”3
In 2017, Carter et al.4 reviewed 70 studies using suicide risk scales to stratify patients in higher-risk groups for self-harm or suicide, during a follow-up period. The study reviewed biological tests such as the dexamethasone suppression test and 5-hydroxyindoleacetic acid; as well as psychological scales, including Buglass & Horton, SADPERSONS, the Beck Hopelessness Scale, the Beck’s Depression Inventory, Manchester Self Harm Rule, and the Edinburgh Risk Rating Scale. Their conclusion was clear: “No individual predictive instrument or pooled subgroups of instruments were able to classify patients as being at high risk of suicidal behavior with a level of accuracy suitable to be used to allocate treatment.”
Despite the bad reputation, one must admit that suicide contracts intuitively feel right. Just as we ask patients whether they believe they will stay sober in the future, or ask patients if they will be compliant with their psychotropics, asking them if they feel that they can maintain safety seems relevant. Reading through the literature, one can even find articles promoting this approach. In 2011, researchers simply asked 147 patients in psychiatric hospitals considered to be high risk for suicide whether they would engage in self-harm in the following weeks. They followed those patients for 15 weeks after their discharge for acts of self-harm. They concluded that “self-perceptions of risk seem to perform as well as the best [standardized assessment tools] the field has to offer” for the prediction of self-harm.5 We are unconvinced that juries would find suicide contracts irrelevant despite the lack of evidence. American society values individual autonomy and self-decision making. Patients telling their clinicians, “I will be OK” is relevant to suicide risk assessment. One can argue that the problem is not with the suicide contract itself, but with its blind use as a marker of safety.
The standard of care dictates that we try to assess suicide risk using evidence-based techniques. To the providers who see merit in asking patients whether they will be able to maintain their safety, we empathize with this impulse despite the lack of evidence. This will contribute in our shared effort to minimize suicide.
We acknowledge that the evidence of any assessment is limited and might miss a greater point in this entire discussion: Why are new iterations of suicide risk assessments not an improvement on the prior ones but a competing theory? New assessments emphasizing different facets of suicidal thinking do not include key demographic factors, while older tools do not include more recent understanding, such as the importance of hopelessness. From a provider’s perspective, the debate appears to be a battle of trends, theories, and acronyms rather than comprehensive analysis of the latest evidence. We, therefore, are concerned by “suicide experts” who advocate for any one assessment as the only gold standard and give false hopes about its efficacy.
As suicide rates continue to climb across the country, one wonders what we, as psychiatrists, are trying to achieve. Promises of zero suicides by hospitals,6 academic institutions,7 and even governments8 are well-meaning but possibly misleading to families and patients. Psychiatry should advocate within the standard of care for reasonable attempts at suicide risk assessment, including demographic factors (see SADPERSONS), as well as examination of the actual suicidality (see the CSSRS). Our professional organizations should clarify expectations for clinicians while also clarifying the limitations of our current knowledge base.
References
1. Patterson WM et al. Evaluation of suicidal patients: the SADPERSONS scale. Psychosomatics. 1983 Apr;24[4]:343-5, 348-9.
2. Posner K et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266-77.
3. Kendall T et al. Longer term management of self harm: summary of NICE guidance. BMJ. 2011;343. doi: 10.1136/bmj.d7073.
4. Carter G et al. Predicting suicidal behaviors using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017 Jun;210(6):387-95.
5. Peterson J et al. If you want to know, consider asking: How likely is it that patients will hurt themselves in the future? Psychol Assess. 2011 Sep;23(3):626-34.
5. Byrne JM et al. Implementation and impact of the central district of California’s suicide prevention program for crime defendants. Federal Probation. 2012 Jun;76(1):3-13.
6. “R.I.’s Butler Hospital sets ‘zero suicide’ goal for patients”/audio. Providence Journal. May 15, 2018.
7. “NIMH funds 3 ‘zero suicide’ grants.” National Institute of Mental Health. Sep 16, 2016.
8. Rothschild N. “Is it possible to eliminate suicide?” Atlantic. Jun 5, 2015.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.
Every guideline and lecture on suicide risk assessment includes the message: “Do not use suicide contracts.” Yet, as forensic psychiatrists, we continue to see medical records that rely solely on the patient verbalizing, agreeing, or signing that they will be safe, in order to justify medical decision-making. A recent case we reviewed involving a grossly psychotic male spotlighted the meaninglessness of suicide contracts. In an attempt to understand the impulse by clinicians to use suicide contracts, we decided to review the topic.
Suicide risk assessment is a confusing and poorly explained skill in our field. Suicide risk assessment tools are well-intended. They are meant to identify and stratify risk, and help guide medical decision-making. Popular tools are startlingly different. How can two scales represent adequate psychiatric knowledge yet be completely different? SADPERSONS1 is widely used and still considered standard of care yet has nothing in common with the Columbia–Suicide Severity Rating Scale (CSSRS).2
For those of us working in forensic settings, we are aghast that neither assessment is modified for use in correctional settings or accounts for essential risk factors of suicide in jails and prisons (placement in solitary, significant charges, homeless, etc.) Yet, they are widely used in jails and prisons across the country. This can be extrapolated to all of us who work with specific populations yet are asked to follow generic scales by administrators.
In reviewing the literature, we are surprised to see the lack of acknowledgment that many tools used in suicide risk assessment have little to no evidence. Despite their numerous appearances in medical records that we review, we are not aware of existing evidence for asking patients whether patients are suicidal on an hourly basis, for psychotropic treatment other than lithium and clozapine (Clozaril), and for safety plans that involve telling the patient to call 911. Of even greater concern, suicide risk assessments themselves may have limited value because of a lack of evidence as suggested by large study findings. It may surprise some to learn that the National Institute for Health and Care Excellence (NICE) in the United Kingdom includes the following statement in its guidelines: “Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.”3
In 2017, Carter et al.4 reviewed 70 studies using suicide risk scales to stratify patients in higher-risk groups for self-harm or suicide, during a follow-up period. The study reviewed biological tests such as the dexamethasone suppression test and 5-hydroxyindoleacetic acid; as well as psychological scales, including Buglass & Horton, SADPERSONS, the Beck Hopelessness Scale, the Beck’s Depression Inventory, Manchester Self Harm Rule, and the Edinburgh Risk Rating Scale. Their conclusion was clear: “No individual predictive instrument or pooled subgroups of instruments were able to classify patients as being at high risk of suicidal behavior with a level of accuracy suitable to be used to allocate treatment.”
Despite the bad reputation, one must admit that suicide contracts intuitively feel right. Just as we ask patients whether they believe they will stay sober in the future, or ask patients if they will be compliant with their psychotropics, asking them if they feel that they can maintain safety seems relevant. Reading through the literature, one can even find articles promoting this approach. In 2011, researchers simply asked 147 patients in psychiatric hospitals considered to be high risk for suicide whether they would engage in self-harm in the following weeks. They followed those patients for 15 weeks after their discharge for acts of self-harm. They concluded that “self-perceptions of risk seem to perform as well as the best [standardized assessment tools] the field has to offer” for the prediction of self-harm.5 We are unconvinced that juries would find suicide contracts irrelevant despite the lack of evidence. American society values individual autonomy and self-decision making. Patients telling their clinicians, “I will be OK” is relevant to suicide risk assessment. One can argue that the problem is not with the suicide contract itself, but with its blind use as a marker of safety.
The standard of care dictates that we try to assess suicide risk using evidence-based techniques. To the providers who see merit in asking patients whether they will be able to maintain their safety, we empathize with this impulse despite the lack of evidence. This will contribute in our shared effort to minimize suicide.
We acknowledge that the evidence of any assessment is limited and might miss a greater point in this entire discussion: Why are new iterations of suicide risk assessments not an improvement on the prior ones but a competing theory? New assessments emphasizing different facets of suicidal thinking do not include key demographic factors, while older tools do not include more recent understanding, such as the importance of hopelessness. From a provider’s perspective, the debate appears to be a battle of trends, theories, and acronyms rather than comprehensive analysis of the latest evidence. We, therefore, are concerned by “suicide experts” who advocate for any one assessment as the only gold standard and give false hopes about its efficacy.
As suicide rates continue to climb across the country, one wonders what we, as psychiatrists, are trying to achieve. Promises of zero suicides by hospitals,6 academic institutions,7 and even governments8 are well-meaning but possibly misleading to families and patients. Psychiatry should advocate within the standard of care for reasonable attempts at suicide risk assessment, including demographic factors (see SADPERSONS), as well as examination of the actual suicidality (see the CSSRS). Our professional organizations should clarify expectations for clinicians while also clarifying the limitations of our current knowledge base.
References
1. Patterson WM et al. Evaluation of suicidal patients: the SADPERSONS scale. Psychosomatics. 1983 Apr;24[4]:343-5, 348-9.
2. Posner K et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266-77.
3. Kendall T et al. Longer term management of self harm: summary of NICE guidance. BMJ. 2011;343. doi: 10.1136/bmj.d7073.
4. Carter G et al. Predicting suicidal behaviors using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017 Jun;210(6):387-95.
5. Peterson J et al. If you want to know, consider asking: How likely is it that patients will hurt themselves in the future? Psychol Assess. 2011 Sep;23(3):626-34.
5. Byrne JM et al. Implementation and impact of the central district of California’s suicide prevention program for crime defendants. Federal Probation. 2012 Jun;76(1):3-13.
6. “R.I.’s Butler Hospital sets ‘zero suicide’ goal for patients”/audio. Providence Journal. May 15, 2018.
7. “NIMH funds 3 ‘zero suicide’ grants.” National Institute of Mental Health. Sep 16, 2016.
8. Rothschild N. “Is it possible to eliminate suicide?” Atlantic. Jun 5, 2015.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.
Every guideline and lecture on suicide risk assessment includes the message: “Do not use suicide contracts.” Yet, as forensic psychiatrists, we continue to see medical records that rely solely on the patient verbalizing, agreeing, or signing that they will be safe, in order to justify medical decision-making. A recent case we reviewed involving a grossly psychotic male spotlighted the meaninglessness of suicide contracts. In an attempt to understand the impulse by clinicians to use suicide contracts, we decided to review the topic.
Suicide risk assessment is a confusing and poorly explained skill in our field. Suicide risk assessment tools are well-intended. They are meant to identify and stratify risk, and help guide medical decision-making. Popular tools are startlingly different. How can two scales represent adequate psychiatric knowledge yet be completely different? SADPERSONS1 is widely used and still considered standard of care yet has nothing in common with the Columbia–Suicide Severity Rating Scale (CSSRS).2
For those of us working in forensic settings, we are aghast that neither assessment is modified for use in correctional settings or accounts for essential risk factors of suicide in jails and prisons (placement in solitary, significant charges, homeless, etc.) Yet, they are widely used in jails and prisons across the country. This can be extrapolated to all of us who work with specific populations yet are asked to follow generic scales by administrators.
In reviewing the literature, we are surprised to see the lack of acknowledgment that many tools used in suicide risk assessment have little to no evidence. Despite their numerous appearances in medical records that we review, we are not aware of existing evidence for asking patients whether patients are suicidal on an hourly basis, for psychotropic treatment other than lithium and clozapine (Clozaril), and for safety plans that involve telling the patient to call 911. Of even greater concern, suicide risk assessments themselves may have limited value because of a lack of evidence as suggested by large study findings. It may surprise some to learn that the National Institute for Health and Care Excellence (NICE) in the United Kingdom includes the following statement in its guidelines: “Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.”3
In 2017, Carter et al.4 reviewed 70 studies using suicide risk scales to stratify patients in higher-risk groups for self-harm or suicide, during a follow-up period. The study reviewed biological tests such as the dexamethasone suppression test and 5-hydroxyindoleacetic acid; as well as psychological scales, including Buglass & Horton, SADPERSONS, the Beck Hopelessness Scale, the Beck’s Depression Inventory, Manchester Self Harm Rule, and the Edinburgh Risk Rating Scale. Their conclusion was clear: “No individual predictive instrument or pooled subgroups of instruments were able to classify patients as being at high risk of suicidal behavior with a level of accuracy suitable to be used to allocate treatment.”
Despite the bad reputation, one must admit that suicide contracts intuitively feel right. Just as we ask patients whether they believe they will stay sober in the future, or ask patients if they will be compliant with their psychotropics, asking them if they feel that they can maintain safety seems relevant. Reading through the literature, one can even find articles promoting this approach. In 2011, researchers simply asked 147 patients in psychiatric hospitals considered to be high risk for suicide whether they would engage in self-harm in the following weeks. They followed those patients for 15 weeks after their discharge for acts of self-harm. They concluded that “self-perceptions of risk seem to perform as well as the best [standardized assessment tools] the field has to offer” for the prediction of self-harm.5 We are unconvinced that juries would find suicide contracts irrelevant despite the lack of evidence. American society values individual autonomy and self-decision making. Patients telling their clinicians, “I will be OK” is relevant to suicide risk assessment. One can argue that the problem is not with the suicide contract itself, but with its blind use as a marker of safety.
The standard of care dictates that we try to assess suicide risk using evidence-based techniques. To the providers who see merit in asking patients whether they will be able to maintain their safety, we empathize with this impulse despite the lack of evidence. This will contribute in our shared effort to minimize suicide.
We acknowledge that the evidence of any assessment is limited and might miss a greater point in this entire discussion: Why are new iterations of suicide risk assessments not an improvement on the prior ones but a competing theory? New assessments emphasizing different facets of suicidal thinking do not include key demographic factors, while older tools do not include more recent understanding, such as the importance of hopelessness. From a provider’s perspective, the debate appears to be a battle of trends, theories, and acronyms rather than comprehensive analysis of the latest evidence. We, therefore, are concerned by “suicide experts” who advocate for any one assessment as the only gold standard and give false hopes about its efficacy.
As suicide rates continue to climb across the country, one wonders what we, as psychiatrists, are trying to achieve. Promises of zero suicides by hospitals,6 academic institutions,7 and even governments8 are well-meaning but possibly misleading to families and patients. Psychiatry should advocate within the standard of care for reasonable attempts at suicide risk assessment, including demographic factors (see SADPERSONS), as well as examination of the actual suicidality (see the CSSRS). Our professional organizations should clarify expectations for clinicians while also clarifying the limitations of our current knowledge base.
References
1. Patterson WM et al. Evaluation of suicidal patients: the SADPERSONS scale. Psychosomatics. 1983 Apr;24[4]:343-5, 348-9.
2. Posner K et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266-77.
3. Kendall T et al. Longer term management of self harm: summary of NICE guidance. BMJ. 2011;343. doi: 10.1136/bmj.d7073.
4. Carter G et al. Predicting suicidal behaviors using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017 Jun;210(6):387-95.
5. Peterson J et al. If you want to know, consider asking: How likely is it that patients will hurt themselves in the future? Psychol Assess. 2011 Sep;23(3):626-34.
5. Byrne JM et al. Implementation and impact of the central district of California’s suicide prevention program for crime defendants. Federal Probation. 2012 Jun;76(1):3-13.
6. “R.I.’s Butler Hospital sets ‘zero suicide’ goal for patients”/audio. Providence Journal. May 15, 2018.
7. “NIMH funds 3 ‘zero suicide’ grants.” National Institute of Mental Health. Sep 16, 2016.
8. Rothschild N. “Is it possible to eliminate suicide?” Atlantic. Jun 5, 2015.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.
Should we defend the unrestrained availability of patented psychotropics?
Since the biological revolution in psychiatry, with the introduction of chlorpromazine in the 1950s,1 psychiatrists have been introduced to the economic questions inherent in the tension between funding psychotropic medications for the treatment of mental illness versus funding psychosocial interventions. Of course, our natural inclination is to advocate for all available treatments for our patients, but the economic realities of medical care – especially government-subsidized or regulated medical care – force us to weigh the relative advantages of these treatments and to promote our patients’ interests with a wise allocation of limited resources.
It has become common practice for the American Psychiatric Association to advocate for additional funds for both research into mental illness as well as treatment. The promotion of mental health parity and the demonization of prior authorizations are examples of our natural priorities in the debates over funding for medical care. A bias has played out in the national conversation about medical care in general regarding the right to said care, but economists understand that medical care is a limited resource and, as such, treating it as a “right,” per se, does not make sense: One has to make hard decisions about its allocation or simply leave it to the free market to make said decisions.
Recently, the government has proposed to eliminate certain psychotropic medications from their protected status within Medicare Part D. Those medications include all drugs labeled as antidepressants, antipsychotics, and anticonvulsants. As expected, the APA’s medical director has written a formal statement opposing the proposal. His statement includes warnings about suicides and overwhelmed emergency departments. He compared the mental health situation in the United States to a crisis. He described the availability of expensive and new psychotropics to be “lifesaving.”2
The goals of the APA and its leaders are honorable. We are inspired by the dedication that some psychiatrists have to advocate for us all as well as for our patients. However, we are concerned that unfounded claims are being made. We are even more troubled when those claims promote the interests of a fallible pharmaceutical industry, an industry that has opened up our field to extensive critical scrutiny over the past few years. We wonder whether a brief examination of the scientific evidence warrants the statements made by the APA.
After reviewing clinical textbooks and search engines, we were not able to find reliable and convincing evidence that newer psychotropics reduce emergency department stays or that lengths of stay in the hospital correlate with the use of newer agents. We have actually not even heard of that claim made before in any serious forum. Reviews of predictors of length of stay in psychiatric hospitals have typically included demographic factors, diagnostic factors, logistical factors such as time of day, and social factors, such as insurance status and homelessness.3,4 We found no review mentioning the use of patented drugs as a predictor of shorter stays.
At a larger level, The Food and Drug Administration approves psychiatric medications based on superiority to placebo and not superiority to existing – and usually much cheaper – medications. Our subscription to Epocrates informs us that a 1-month supply of once-a-day brand-name Abilify, Invega, or Latuda is more than $1,000.5 Alternatively, a 1-month supply of generic olanzapine, risperidone, or quetiapine is available for $4 at Walmart.6 As famously described in the CATIE trial7 of patients with schizophrenia, newer antipsychotics are not particularly better than older ones. In addition, a more recent meta-analysis8 did not find significant differences among antipsychotics’ efficacy.
A similar analysis can be made of antidepressants without addressing debates surrounding the effectiveness of antidepressants as a class and the value of psychological interventions over chemical ones. Reviews of the literature do not suggest that newer antidepressants are more effective than older ones. A recent meta-analysis of antidepressant efficacy did not find significant differences among antidepressants and, when looking at trends, amitriptyline, a much older antidepressant, was most effective.9
The most surprising part of the APA medical director’s statement was the claim of reduced suicidality. While lithium and clozapine have some evidence for reducing the risk of suicide, the evidence that antidepressants reduce suicide is equivocal. Quite the contrary, some evidence exists that antidepressants may increase the risk of suicide,10 and we are not aware of evidence suggesting that any newer agents can reduce suicide at any higher rate. One psychiatrist has even made a career out of testifying that antidepressants increase impulsivity and suicide.11
We are not politicians, and we trust the APA to have good intentions with a desire to help patients suffering from mental illness. We understand the need to advocate for any measure that provides additional resources for the treatment of mental illness. We have no doubt that a publicly funded and appropriately regulated mental health system is a wise goal from both an ethical as well as a societal perspective. The APA has an imperative to advocate for our patients with the goal to improve our society.
However, we are concerned when our field makes unfounded claims. Advocating that insurance companies and the government provide most psychotropics without prior authorization and without discrimination does not appear to be based on scientific evidence and has serious economic implications that are not being weighed in a transparent manner. Whatever funding levels the APA recommends for the treatment of mental illness, said treatments will remain a limited resource, and then it becomes a question not just of ethics but of economics. What combination of resources produce the most benefit for the most people in question? Would the increased cost of a newer psychotropic be better spent on a system with more elaborate psychosocial interventions? In making this argument, does one risk repeating the historical blunder made when, in the 1960s, long-term psychiatric hospitals were closed with the intention of replacing their costs with outpatient treatments that then never materialized?
A review of the literature does not support the claim that newer psychotropic agents are more effective from either a clinical or an economic perspective. Cost-saving measures are ethical and possibly beneficial if they permit a more justifiable allocation of resources.
Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He is also the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Among his writings is Chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019).
References
1. Ann Med Psychol (Paris). 1952 Jun;110(2 1):112-7.
2. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2019.3b26.
3. Am J Emerg Med. 2016 Feb;34(2):133-9.
4. Eur Psychiatry. 2018 Feb;48:6-12.
5. https://online.epocrates.com/drugs. Retrieved March 3, 2019.
6. https://www.walmart.com/cp/$4-prescriptions/1078664. Retrieved March 27, 2019.
7. N Engl J Med. 2005 Sep 22;353(12):1209-23.
8. Am J Psychiatry. 2017. 174(10):927-42.
9. Lancet. 2018 Apr 7. 391(10128):P1357-66.
10. BMJ. 2009.339;b2880.
11. https://breggin.com/.
Since the biological revolution in psychiatry, with the introduction of chlorpromazine in the 1950s,1 psychiatrists have been introduced to the economic questions inherent in the tension between funding psychotropic medications for the treatment of mental illness versus funding psychosocial interventions. Of course, our natural inclination is to advocate for all available treatments for our patients, but the economic realities of medical care – especially government-subsidized or regulated medical care – force us to weigh the relative advantages of these treatments and to promote our patients’ interests with a wise allocation of limited resources.
It has become common practice for the American Psychiatric Association to advocate for additional funds for both research into mental illness as well as treatment. The promotion of mental health parity and the demonization of prior authorizations are examples of our natural priorities in the debates over funding for medical care. A bias has played out in the national conversation about medical care in general regarding the right to said care, but economists understand that medical care is a limited resource and, as such, treating it as a “right,” per se, does not make sense: One has to make hard decisions about its allocation or simply leave it to the free market to make said decisions.
Recently, the government has proposed to eliminate certain psychotropic medications from their protected status within Medicare Part D. Those medications include all drugs labeled as antidepressants, antipsychotics, and anticonvulsants. As expected, the APA’s medical director has written a formal statement opposing the proposal. His statement includes warnings about suicides and overwhelmed emergency departments. He compared the mental health situation in the United States to a crisis. He described the availability of expensive and new psychotropics to be “lifesaving.”2
The goals of the APA and its leaders are honorable. We are inspired by the dedication that some psychiatrists have to advocate for us all as well as for our patients. However, we are concerned that unfounded claims are being made. We are even more troubled when those claims promote the interests of a fallible pharmaceutical industry, an industry that has opened up our field to extensive critical scrutiny over the past few years. We wonder whether a brief examination of the scientific evidence warrants the statements made by the APA.
After reviewing clinical textbooks and search engines, we were not able to find reliable and convincing evidence that newer psychotropics reduce emergency department stays or that lengths of stay in the hospital correlate with the use of newer agents. We have actually not even heard of that claim made before in any serious forum. Reviews of predictors of length of stay in psychiatric hospitals have typically included demographic factors, diagnostic factors, logistical factors such as time of day, and social factors, such as insurance status and homelessness.3,4 We found no review mentioning the use of patented drugs as a predictor of shorter stays.
At a larger level, The Food and Drug Administration approves psychiatric medications based on superiority to placebo and not superiority to existing – and usually much cheaper – medications. Our subscription to Epocrates informs us that a 1-month supply of once-a-day brand-name Abilify, Invega, or Latuda is more than $1,000.5 Alternatively, a 1-month supply of generic olanzapine, risperidone, or quetiapine is available for $4 at Walmart.6 As famously described in the CATIE trial7 of patients with schizophrenia, newer antipsychotics are not particularly better than older ones. In addition, a more recent meta-analysis8 did not find significant differences among antipsychotics’ efficacy.
A similar analysis can be made of antidepressants without addressing debates surrounding the effectiveness of antidepressants as a class and the value of psychological interventions over chemical ones. Reviews of the literature do not suggest that newer antidepressants are more effective than older ones. A recent meta-analysis of antidepressant efficacy did not find significant differences among antidepressants and, when looking at trends, amitriptyline, a much older antidepressant, was most effective.9
The most surprising part of the APA medical director’s statement was the claim of reduced suicidality. While lithium and clozapine have some evidence for reducing the risk of suicide, the evidence that antidepressants reduce suicide is equivocal. Quite the contrary, some evidence exists that antidepressants may increase the risk of suicide,10 and we are not aware of evidence suggesting that any newer agents can reduce suicide at any higher rate. One psychiatrist has even made a career out of testifying that antidepressants increase impulsivity and suicide.11
We are not politicians, and we trust the APA to have good intentions with a desire to help patients suffering from mental illness. We understand the need to advocate for any measure that provides additional resources for the treatment of mental illness. We have no doubt that a publicly funded and appropriately regulated mental health system is a wise goal from both an ethical as well as a societal perspective. The APA has an imperative to advocate for our patients with the goal to improve our society.
However, we are concerned when our field makes unfounded claims. Advocating that insurance companies and the government provide most psychotropics without prior authorization and without discrimination does not appear to be based on scientific evidence and has serious economic implications that are not being weighed in a transparent manner. Whatever funding levels the APA recommends for the treatment of mental illness, said treatments will remain a limited resource, and then it becomes a question not just of ethics but of economics. What combination of resources produce the most benefit for the most people in question? Would the increased cost of a newer psychotropic be better spent on a system with more elaborate psychosocial interventions? In making this argument, does one risk repeating the historical blunder made when, in the 1960s, long-term psychiatric hospitals were closed with the intention of replacing their costs with outpatient treatments that then never materialized?
A review of the literature does not support the claim that newer psychotropic agents are more effective from either a clinical or an economic perspective. Cost-saving measures are ethical and possibly beneficial if they permit a more justifiable allocation of resources.
Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He is also the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Among his writings is Chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019).
References
1. Ann Med Psychol (Paris). 1952 Jun;110(2 1):112-7.
2. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2019.3b26.
3. Am J Emerg Med. 2016 Feb;34(2):133-9.
4. Eur Psychiatry. 2018 Feb;48:6-12.
5. https://online.epocrates.com/drugs. Retrieved March 3, 2019.
6. https://www.walmart.com/cp/$4-prescriptions/1078664. Retrieved March 27, 2019.
7. N Engl J Med. 2005 Sep 22;353(12):1209-23.
8. Am J Psychiatry. 2017. 174(10):927-42.
9. Lancet. 2018 Apr 7. 391(10128):P1357-66.
10. BMJ. 2009.339;b2880.
11. https://breggin.com/.
Since the biological revolution in psychiatry, with the introduction of chlorpromazine in the 1950s,1 psychiatrists have been introduced to the economic questions inherent in the tension between funding psychotropic medications for the treatment of mental illness versus funding psychosocial interventions. Of course, our natural inclination is to advocate for all available treatments for our patients, but the economic realities of medical care – especially government-subsidized or regulated medical care – force us to weigh the relative advantages of these treatments and to promote our patients’ interests with a wise allocation of limited resources.
It has become common practice for the American Psychiatric Association to advocate for additional funds for both research into mental illness as well as treatment. The promotion of mental health parity and the demonization of prior authorizations are examples of our natural priorities in the debates over funding for medical care. A bias has played out in the national conversation about medical care in general regarding the right to said care, but economists understand that medical care is a limited resource and, as such, treating it as a “right,” per se, does not make sense: One has to make hard decisions about its allocation or simply leave it to the free market to make said decisions.
Recently, the government has proposed to eliminate certain psychotropic medications from their protected status within Medicare Part D. Those medications include all drugs labeled as antidepressants, antipsychotics, and anticonvulsants. As expected, the APA’s medical director has written a formal statement opposing the proposal. His statement includes warnings about suicides and overwhelmed emergency departments. He compared the mental health situation in the United States to a crisis. He described the availability of expensive and new psychotropics to be “lifesaving.”2
The goals of the APA and its leaders are honorable. We are inspired by the dedication that some psychiatrists have to advocate for us all as well as for our patients. However, we are concerned that unfounded claims are being made. We are even more troubled when those claims promote the interests of a fallible pharmaceutical industry, an industry that has opened up our field to extensive critical scrutiny over the past few years. We wonder whether a brief examination of the scientific evidence warrants the statements made by the APA.
After reviewing clinical textbooks and search engines, we were not able to find reliable and convincing evidence that newer psychotropics reduce emergency department stays or that lengths of stay in the hospital correlate with the use of newer agents. We have actually not even heard of that claim made before in any serious forum. Reviews of predictors of length of stay in psychiatric hospitals have typically included demographic factors, diagnostic factors, logistical factors such as time of day, and social factors, such as insurance status and homelessness.3,4 We found no review mentioning the use of patented drugs as a predictor of shorter stays.
At a larger level, The Food and Drug Administration approves psychiatric medications based on superiority to placebo and not superiority to existing – and usually much cheaper – medications. Our subscription to Epocrates informs us that a 1-month supply of once-a-day brand-name Abilify, Invega, or Latuda is more than $1,000.5 Alternatively, a 1-month supply of generic olanzapine, risperidone, or quetiapine is available for $4 at Walmart.6 As famously described in the CATIE trial7 of patients with schizophrenia, newer antipsychotics are not particularly better than older ones. In addition, a more recent meta-analysis8 did not find significant differences among antipsychotics’ efficacy.
A similar analysis can be made of antidepressants without addressing debates surrounding the effectiveness of antidepressants as a class and the value of psychological interventions over chemical ones. Reviews of the literature do not suggest that newer antidepressants are more effective than older ones. A recent meta-analysis of antidepressant efficacy did not find significant differences among antidepressants and, when looking at trends, amitriptyline, a much older antidepressant, was most effective.9
The most surprising part of the APA medical director’s statement was the claim of reduced suicidality. While lithium and clozapine have some evidence for reducing the risk of suicide, the evidence that antidepressants reduce suicide is equivocal. Quite the contrary, some evidence exists that antidepressants may increase the risk of suicide,10 and we are not aware of evidence suggesting that any newer agents can reduce suicide at any higher rate. One psychiatrist has even made a career out of testifying that antidepressants increase impulsivity and suicide.11
We are not politicians, and we trust the APA to have good intentions with a desire to help patients suffering from mental illness. We understand the need to advocate for any measure that provides additional resources for the treatment of mental illness. We have no doubt that a publicly funded and appropriately regulated mental health system is a wise goal from both an ethical as well as a societal perspective. The APA has an imperative to advocate for our patients with the goal to improve our society.
However, we are concerned when our field makes unfounded claims. Advocating that insurance companies and the government provide most psychotropics without prior authorization and without discrimination does not appear to be based on scientific evidence and has serious economic implications that are not being weighed in a transparent manner. Whatever funding levels the APA recommends for the treatment of mental illness, said treatments will remain a limited resource, and then it becomes a question not just of ethics but of economics. What combination of resources produce the most benefit for the most people in question? Would the increased cost of a newer psychotropic be better spent on a system with more elaborate psychosocial interventions? In making this argument, does one risk repeating the historical blunder made when, in the 1960s, long-term psychiatric hospitals were closed with the intention of replacing their costs with outpatient treatments that then never materialized?
A review of the literature does not support the claim that newer psychotropic agents are more effective from either a clinical or an economic perspective. Cost-saving measures are ethical and possibly beneficial if they permit a more justifiable allocation of resources.
Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He is also the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Among his writings is Chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019).
References
1. Ann Med Psychol (Paris). 1952 Jun;110(2 1):112-7.
2. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2019.3b26.
3. Am J Emerg Med. 2016 Feb;34(2):133-9.
4. Eur Psychiatry. 2018 Feb;48:6-12.
5. https://online.epocrates.com/drugs. Retrieved March 3, 2019.
6. https://www.walmart.com/cp/$4-prescriptions/1078664. Retrieved March 27, 2019.
7. N Engl J Med. 2005 Sep 22;353(12):1209-23.
8. Am J Psychiatry. 2017. 174(10):927-42.
9. Lancet. 2018 Apr 7. 391(10128):P1357-66.
10. BMJ. 2009.339;b2880.
11. https://breggin.com/.
Depression: a changing concept in the age of ketamine
What does it mean to define an amalgamation of symptoms as a “psychiatric disorder?” Are psychiatric disorders an extreme variation of normative human behavior? Is human behavior simply an output phenotype of some neurologic chemical processes that become disordered in mental illness? Can depression be localized in the brain and subsequently turned on or off? If depression were to be localized in the brain, would it be an excess of a neurotransmitter, the depletion of a receptor, a malfunctioning neuron, an overactive connectome, poorly processed genetic material, or something as yet undefined? Those questions always have been present in our minds and influenced our understanding of patients, but a recent development in psychiatry raises questions about one of the few things we were historically confident about.
A part of our foundational understanding of depression was that it is not sadness, per se. One can be sad for any amount of time. It is not uncommon to feel sad for any variety of reasons, such as watching an adorable 60-second commercial for dog food.1 Those fleeting moments of sadness can even be empowering; they remind us about the things we care about and would be sad to miss.
Sadness in oneself can demonstrate the experience of empathic sadness for others. On the contrary, depression appears to have little apparent purpose, and instead results in a maladaptive way of coping that is all-consuming and often very damaging. Depression is not a mood but a state of being, something that is not defined by how one feels but who one is or has become because of the disorder. So it comes as somewhat of a surprise when we heard that ketamine could alleviate depression in minutes.2,3 As described by a ketamine expert, symptoms are relieved in “no less than an hour.”4 The surprise is not so much that a treatment would work but that improvement could be defined in such a short time frame.
Psychiatry has debated the definition of depression for its entire existence. There are many ways to tackle the concept of depression. A lot of the debate has been about the causes of depression. One example of the continued evolution of our understanding of depression is our prior categorization of depression as “exogenous” or “endogenous.”5 Exogenous depression was described as happening in the context of social stressors and as best treated with therapy. Endogenous depression was a supposedly truer form of depression as a disorder and was more biologically based. Patients suffering from endogenous depression were thought to have chemical abnormalities in the brain that could be alleviated by tricyclic antidepressants and subsequently SSRIs. Like many prior debates about depression, this one appears to be little discussed nowadays. A review of the use of the term “endogenous depression” in books shows an onset in the 1930s, a peak in the 1980s, and a rapid decline since.6
More recently, psychiatrists have defined depression using the DSM-5 criteria. Depression is thought to be the presence of at least five out of nine symptoms listed in the manual for a period of 2 weeks that cause significant distress or impairment.7 The DSM attempts to address criticism by providing information on its limitations and best use, and encourages clinical interpretation of symptoms. The DSM does not portray itself as a gold standard but rather as a tool for treatment planning and effective communication between peers. Furthermore, the National Institute on Mental Health is promoting an alternative understanding of depression using its own Research Domain Criteria, which attempt to provide a more objective understanding of the disorder based on biological rather than subjective correlates.
The growing literature on ketamine partly hinges on the belief that depression is something that can be redefined and changed at any moment. Many trials ask patients whether their depression remains in remission in the subsequent hours, days, and weeks following administration of the drug. However, one wonders if that is even possible. If a patient’s depression is alleviated in an hour, was it really clinical depression? Is it truly in remission? Contrary to our previous understanding, is depression, in reality, a switch that can be turned off by an infusion of an N-methyl-D-aspartate (NMDA)–receptor antagonist? Without minimizing the suffering of patients seeking ketamine or the relief provided to patients who benefit from the treatment, we simply are pointing out that the definition of depression did not account for this reported phenomenon of relatively instantaneous relief. The seemingly miraculous effects of ketamine suggest a new paradigm where any intervention – whether chemical, social, or psychological – could turn off the devastating effects of depression in an instant.
After all, the most widely used scale of depression, the nine-item Patient Health Questionnaire (PHQ-9) asks patients, “Over the last 2 weeks, how often have you been bothered by any of the following problems?” The highest answer one can give is “Nearly every day.” Are we incorrect to think that if one were suicidal every minute of the past 2 weeks, one would still score, nearly every day, even if one’s symptoms were relieved for the past hour? Thus, a maximum score of 27 would remain a 27 no matter what happened in the past hour.
We do realize that we are being overly literal. Ketamine makes some people feel better quickly, and researchers try to capture that effect by asking patients about their symptoms within short intervals. Furthermore, one has to start somewhere. After the infusion is a reasonable time to ask patients how they feel. We are also cognizant that many ketamine researchers do more long-term follow-ups and/or have recommended longer-term studies. Nonetheless,
Expanding our definition of depression to encompass experiences with short time frames may have unintended consequences. As living circumstances rarely change in minutes, the emphasis on rapid recovery makes the patients more in control of their reported experiences and thus their diagnoses. One cannot assess a patient’s impairment or disability from minute to minute. One is left with emphasizing the patient’s subjective symptoms and deemphasizing their relationships, goals, and daily functioning. How could one measure eating habits, hygiene, or participation in hobbies every hour? Another consequence of this reduced time frame is the expansion of a diagnosis that no longer requires the presence of symptoms for 2 weeks. Considering the already vast number of people diagnosed with depression,9,10 this small change may further expand the number diagnosed with a mood disorder. Perhaps to many practitioners and patients these arguments seem obtuse and fastidious, but there is a core failure in modern psychiatry to clearly differentiate the human condition from mental illness. Said failure has vast implications for psychiatric epidemiology, the sociological understanding of psychic suffering and suicide, as well as the overprescribing of psychotropic medications.
Ketamine is an exciting prospect to many psychiatrists who feel like we have had little advancement and few novel treatments in a long time; advertised breakthroughs in the treatment of depression since fluoxetine have not been particularly impressive. Furthermore, the concerns about potential ketamine abuse are not theoretical but a very real problem in some parts of the world.11,12 The concerns about abuse are worsened considering recent evidence that suggests that ketamine’s effect may be driven by its opiate rather than NMDA effects.13 While some have discussed those concerns, we think that the field also needs to address the fact that the debate about ketamine is also changing our definition of depression.
References
1. https://www.youtube.com/watch?v=MpcUN6XvGmk.
2. J Clin Psychiatry. 2016 Jun;77(6):e719-25.
3. Emerg (Tehran). 2014 Winter;2(1):36-9.
4. “Is esketamine the game-changer for depression we want?” Rolling Stone. 2019 Mar 11.
5. Psychol Med. 1971;1(3):191-6.
6. https://books.google.com/ngrams.
7. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). American Psychiatric Association, 2013.
8. Am J Psychiatry. 2014 Apr;171(4):395-7.
9. “Many people taking antidepressants discover they cannot quit.” New York Times. 2018 Apr 7.
10. “Antidepressants show greatest increase in number of prescription items dispensed.” National Health Service. 2015 Jul 5.
11. “The ketamine connection.” BBC News. 2015 Jul 10.
12. Front Psychiatry. 2018 Jul 17. doi: 10.33389/fpsyt.2018.00313.
13. Am J Psychiatry. 2018 Dec 1;175(2):1205-15.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Among his writings is Coercion and the critical psychiatrist, chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer Nature Switzerland, 2019, pp. 155-77). Dr. Lehman is an associate professor of psychiatry at UCSD. He is codirector of all Acute and Intensive Psychiatric Treatment at the VA Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.
*This article was updated 3/25/2019.
What does it mean to define an amalgamation of symptoms as a “psychiatric disorder?” Are psychiatric disorders an extreme variation of normative human behavior? Is human behavior simply an output phenotype of some neurologic chemical processes that become disordered in mental illness? Can depression be localized in the brain and subsequently turned on or off? If depression were to be localized in the brain, would it be an excess of a neurotransmitter, the depletion of a receptor, a malfunctioning neuron, an overactive connectome, poorly processed genetic material, or something as yet undefined? Those questions always have been present in our minds and influenced our understanding of patients, but a recent development in psychiatry raises questions about one of the few things we were historically confident about.
A part of our foundational understanding of depression was that it is not sadness, per se. One can be sad for any amount of time. It is not uncommon to feel sad for any variety of reasons, such as watching an adorable 60-second commercial for dog food.1 Those fleeting moments of sadness can even be empowering; they remind us about the things we care about and would be sad to miss.
Sadness in oneself can demonstrate the experience of empathic sadness for others. On the contrary, depression appears to have little apparent purpose, and instead results in a maladaptive way of coping that is all-consuming and often very damaging. Depression is not a mood but a state of being, something that is not defined by how one feels but who one is or has become because of the disorder. So it comes as somewhat of a surprise when we heard that ketamine could alleviate depression in minutes.2,3 As described by a ketamine expert, symptoms are relieved in “no less than an hour.”4 The surprise is not so much that a treatment would work but that improvement could be defined in such a short time frame.
Psychiatry has debated the definition of depression for its entire existence. There are many ways to tackle the concept of depression. A lot of the debate has been about the causes of depression. One example of the continued evolution of our understanding of depression is our prior categorization of depression as “exogenous” or “endogenous.”5 Exogenous depression was described as happening in the context of social stressors and as best treated with therapy. Endogenous depression was a supposedly truer form of depression as a disorder and was more biologically based. Patients suffering from endogenous depression were thought to have chemical abnormalities in the brain that could be alleviated by tricyclic antidepressants and subsequently SSRIs. Like many prior debates about depression, this one appears to be little discussed nowadays. A review of the use of the term “endogenous depression” in books shows an onset in the 1930s, a peak in the 1980s, and a rapid decline since.6
More recently, psychiatrists have defined depression using the DSM-5 criteria. Depression is thought to be the presence of at least five out of nine symptoms listed in the manual for a period of 2 weeks that cause significant distress or impairment.7 The DSM attempts to address criticism by providing information on its limitations and best use, and encourages clinical interpretation of symptoms. The DSM does not portray itself as a gold standard but rather as a tool for treatment planning and effective communication between peers. Furthermore, the National Institute on Mental Health is promoting an alternative understanding of depression using its own Research Domain Criteria, which attempt to provide a more objective understanding of the disorder based on biological rather than subjective correlates.
The growing literature on ketamine partly hinges on the belief that depression is something that can be redefined and changed at any moment. Many trials ask patients whether their depression remains in remission in the subsequent hours, days, and weeks following administration of the drug. However, one wonders if that is even possible. If a patient’s depression is alleviated in an hour, was it really clinical depression? Is it truly in remission? Contrary to our previous understanding, is depression, in reality, a switch that can be turned off by an infusion of an N-methyl-D-aspartate (NMDA)–receptor antagonist? Without minimizing the suffering of patients seeking ketamine or the relief provided to patients who benefit from the treatment, we simply are pointing out that the definition of depression did not account for this reported phenomenon of relatively instantaneous relief. The seemingly miraculous effects of ketamine suggest a new paradigm where any intervention – whether chemical, social, or psychological – could turn off the devastating effects of depression in an instant.
After all, the most widely used scale of depression, the nine-item Patient Health Questionnaire (PHQ-9) asks patients, “Over the last 2 weeks, how often have you been bothered by any of the following problems?” The highest answer one can give is “Nearly every day.” Are we incorrect to think that if one were suicidal every minute of the past 2 weeks, one would still score, nearly every day, even if one’s symptoms were relieved for the past hour? Thus, a maximum score of 27 would remain a 27 no matter what happened in the past hour.
We do realize that we are being overly literal. Ketamine makes some people feel better quickly, and researchers try to capture that effect by asking patients about their symptoms within short intervals. Furthermore, one has to start somewhere. After the infusion is a reasonable time to ask patients how they feel. We are also cognizant that many ketamine researchers do more long-term follow-ups and/or have recommended longer-term studies. Nonetheless,
Expanding our definition of depression to encompass experiences with short time frames may have unintended consequences. As living circumstances rarely change in minutes, the emphasis on rapid recovery makes the patients more in control of their reported experiences and thus their diagnoses. One cannot assess a patient’s impairment or disability from minute to minute. One is left with emphasizing the patient’s subjective symptoms and deemphasizing their relationships, goals, and daily functioning. How could one measure eating habits, hygiene, or participation in hobbies every hour? Another consequence of this reduced time frame is the expansion of a diagnosis that no longer requires the presence of symptoms for 2 weeks. Considering the already vast number of people diagnosed with depression,9,10 this small change may further expand the number diagnosed with a mood disorder. Perhaps to many practitioners and patients these arguments seem obtuse and fastidious, but there is a core failure in modern psychiatry to clearly differentiate the human condition from mental illness. Said failure has vast implications for psychiatric epidemiology, the sociological understanding of psychic suffering and suicide, as well as the overprescribing of psychotropic medications.
Ketamine is an exciting prospect to many psychiatrists who feel like we have had little advancement and few novel treatments in a long time; advertised breakthroughs in the treatment of depression since fluoxetine have not been particularly impressive. Furthermore, the concerns about potential ketamine abuse are not theoretical but a very real problem in some parts of the world.11,12 The concerns about abuse are worsened considering recent evidence that suggests that ketamine’s effect may be driven by its opiate rather than NMDA effects.13 While some have discussed those concerns, we think that the field also needs to address the fact that the debate about ketamine is also changing our definition of depression.
References
1. https://www.youtube.com/watch?v=MpcUN6XvGmk.
2. J Clin Psychiatry. 2016 Jun;77(6):e719-25.
3. Emerg (Tehran). 2014 Winter;2(1):36-9.
4. “Is esketamine the game-changer for depression we want?” Rolling Stone. 2019 Mar 11.
5. Psychol Med. 1971;1(3):191-6.
6. https://books.google.com/ngrams.
7. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). American Psychiatric Association, 2013.
8. Am J Psychiatry. 2014 Apr;171(4):395-7.
9. “Many people taking antidepressants discover they cannot quit.” New York Times. 2018 Apr 7.
10. “Antidepressants show greatest increase in number of prescription items dispensed.” National Health Service. 2015 Jul 5.
11. “The ketamine connection.” BBC News. 2015 Jul 10.
12. Front Psychiatry. 2018 Jul 17. doi: 10.33389/fpsyt.2018.00313.
13. Am J Psychiatry. 2018 Dec 1;175(2):1205-15.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Among his writings is Coercion and the critical psychiatrist, chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer Nature Switzerland, 2019, pp. 155-77). Dr. Lehman is an associate professor of psychiatry at UCSD. He is codirector of all Acute and Intensive Psychiatric Treatment at the VA Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.
*This article was updated 3/25/2019.
What does it mean to define an amalgamation of symptoms as a “psychiatric disorder?” Are psychiatric disorders an extreme variation of normative human behavior? Is human behavior simply an output phenotype of some neurologic chemical processes that become disordered in mental illness? Can depression be localized in the brain and subsequently turned on or off? If depression were to be localized in the brain, would it be an excess of a neurotransmitter, the depletion of a receptor, a malfunctioning neuron, an overactive connectome, poorly processed genetic material, or something as yet undefined? Those questions always have been present in our minds and influenced our understanding of patients, but a recent development in psychiatry raises questions about one of the few things we were historically confident about.
A part of our foundational understanding of depression was that it is not sadness, per se. One can be sad for any amount of time. It is not uncommon to feel sad for any variety of reasons, such as watching an adorable 60-second commercial for dog food.1 Those fleeting moments of sadness can even be empowering; they remind us about the things we care about and would be sad to miss.
Sadness in oneself can demonstrate the experience of empathic sadness for others. On the contrary, depression appears to have little apparent purpose, and instead results in a maladaptive way of coping that is all-consuming and often very damaging. Depression is not a mood but a state of being, something that is not defined by how one feels but who one is or has become because of the disorder. So it comes as somewhat of a surprise when we heard that ketamine could alleviate depression in minutes.2,3 As described by a ketamine expert, symptoms are relieved in “no less than an hour.”4 The surprise is not so much that a treatment would work but that improvement could be defined in such a short time frame.
Psychiatry has debated the definition of depression for its entire existence. There are many ways to tackle the concept of depression. A lot of the debate has been about the causes of depression. One example of the continued evolution of our understanding of depression is our prior categorization of depression as “exogenous” or “endogenous.”5 Exogenous depression was described as happening in the context of social stressors and as best treated with therapy. Endogenous depression was a supposedly truer form of depression as a disorder and was more biologically based. Patients suffering from endogenous depression were thought to have chemical abnormalities in the brain that could be alleviated by tricyclic antidepressants and subsequently SSRIs. Like many prior debates about depression, this one appears to be little discussed nowadays. A review of the use of the term “endogenous depression” in books shows an onset in the 1930s, a peak in the 1980s, and a rapid decline since.6
More recently, psychiatrists have defined depression using the DSM-5 criteria. Depression is thought to be the presence of at least five out of nine symptoms listed in the manual for a period of 2 weeks that cause significant distress or impairment.7 The DSM attempts to address criticism by providing information on its limitations and best use, and encourages clinical interpretation of symptoms. The DSM does not portray itself as a gold standard but rather as a tool for treatment planning and effective communication between peers. Furthermore, the National Institute on Mental Health is promoting an alternative understanding of depression using its own Research Domain Criteria, which attempt to provide a more objective understanding of the disorder based on biological rather than subjective correlates.
The growing literature on ketamine partly hinges on the belief that depression is something that can be redefined and changed at any moment. Many trials ask patients whether their depression remains in remission in the subsequent hours, days, and weeks following administration of the drug. However, one wonders if that is even possible. If a patient’s depression is alleviated in an hour, was it really clinical depression? Is it truly in remission? Contrary to our previous understanding, is depression, in reality, a switch that can be turned off by an infusion of an N-methyl-D-aspartate (NMDA)–receptor antagonist? Without minimizing the suffering of patients seeking ketamine or the relief provided to patients who benefit from the treatment, we simply are pointing out that the definition of depression did not account for this reported phenomenon of relatively instantaneous relief. The seemingly miraculous effects of ketamine suggest a new paradigm where any intervention – whether chemical, social, or psychological – could turn off the devastating effects of depression in an instant.
After all, the most widely used scale of depression, the nine-item Patient Health Questionnaire (PHQ-9) asks patients, “Over the last 2 weeks, how often have you been bothered by any of the following problems?” The highest answer one can give is “Nearly every day.” Are we incorrect to think that if one were suicidal every minute of the past 2 weeks, one would still score, nearly every day, even if one’s symptoms were relieved for the past hour? Thus, a maximum score of 27 would remain a 27 no matter what happened in the past hour.
We do realize that we are being overly literal. Ketamine makes some people feel better quickly, and researchers try to capture that effect by asking patients about their symptoms within short intervals. Furthermore, one has to start somewhere. After the infusion is a reasonable time to ask patients how they feel. We are also cognizant that many ketamine researchers do more long-term follow-ups and/or have recommended longer-term studies. Nonetheless,
Expanding our definition of depression to encompass experiences with short time frames may have unintended consequences. As living circumstances rarely change in minutes, the emphasis on rapid recovery makes the patients more in control of their reported experiences and thus their diagnoses. One cannot assess a patient’s impairment or disability from minute to minute. One is left with emphasizing the patient’s subjective symptoms and deemphasizing their relationships, goals, and daily functioning. How could one measure eating habits, hygiene, or participation in hobbies every hour? Another consequence of this reduced time frame is the expansion of a diagnosis that no longer requires the presence of symptoms for 2 weeks. Considering the already vast number of people diagnosed with depression,9,10 this small change may further expand the number diagnosed with a mood disorder. Perhaps to many practitioners and patients these arguments seem obtuse and fastidious, but there is a core failure in modern psychiatry to clearly differentiate the human condition from mental illness. Said failure has vast implications for psychiatric epidemiology, the sociological understanding of psychic suffering and suicide, as well as the overprescribing of psychotropic medications.
Ketamine is an exciting prospect to many psychiatrists who feel like we have had little advancement and few novel treatments in a long time; advertised breakthroughs in the treatment of depression since fluoxetine have not been particularly impressive. Furthermore, the concerns about potential ketamine abuse are not theoretical but a very real problem in some parts of the world.11,12 The concerns about abuse are worsened considering recent evidence that suggests that ketamine’s effect may be driven by its opiate rather than NMDA effects.13 While some have discussed those concerns, we think that the field also needs to address the fact that the debate about ketamine is also changing our definition of depression.
References
1. https://www.youtube.com/watch?v=MpcUN6XvGmk.
2. J Clin Psychiatry. 2016 Jun;77(6):e719-25.
3. Emerg (Tehran). 2014 Winter;2(1):36-9.
4. “Is esketamine the game-changer for depression we want?” Rolling Stone. 2019 Mar 11.
5. Psychol Med. 1971;1(3):191-6.
6. https://books.google.com/ngrams.
7. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). American Psychiatric Association, 2013.
8. Am J Psychiatry. 2014 Apr;171(4):395-7.
9. “Many people taking antidepressants discover they cannot quit.” New York Times. 2018 Apr 7.
10. “Antidepressants show greatest increase in number of prescription items dispensed.” National Health Service. 2015 Jul 5.
11. “The ketamine connection.” BBC News. 2015 Jul 10.
12. Front Psychiatry. 2018 Jul 17. doi: 10.33389/fpsyt.2018.00313.
13. Am J Psychiatry. 2018 Dec 1;175(2):1205-15.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Among his writings is Coercion and the critical psychiatrist, chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer Nature Switzerland, 2019, pp. 155-77). Dr. Lehman is an associate professor of psychiatry at UCSD. He is codirector of all Acute and Intensive Psychiatric Treatment at the VA Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.
*This article was updated 3/25/2019.
A prescription for ‘deprescribing’: A case report
In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.1 They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”1
In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants2 and mood stabilizers.3 The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.
Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
Overview of the case
Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.
In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”
When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.
After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.
Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
Initial visit
Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.
When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”
She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.
When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”
Assessment
I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.
Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.
She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.
Treatment plan
We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”
She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.
In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
Outcome
I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.
Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
Discussion
Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.4 There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.
Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.5 Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.6 Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
Take-home points
- Polypharmacy can lead to psychiatric symptoms and functional impairment.
- Patients often are unaware of the complete risks of psychotropics.
- Psychiatric symptoms are not always associated with a psychiatric disorder.
- Deprescribing can be performed safely and effectively.
- Deprescribing can be performed with the patient’s informed consent and agreement.
References
1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.
2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.
3. Bipolar Disord. 2016 Dec;18(8):684-91.
4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.
5. World Psychiatry. 2009 Jun;8(2):67-74.
6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
*This column was updated 1/11/2019.
In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.1 They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”1
In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants2 and mood stabilizers.3 The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.
Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
Overview of the case
Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.
In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”
When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.
After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.
Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
Initial visit
Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.
When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”
She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.
When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”
Assessment
I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.
Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.
She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.
Treatment plan
We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”
She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.
In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
Outcome
I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.
Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
Discussion
Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.4 There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.
Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.5 Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.6 Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
Take-home points
- Polypharmacy can lead to psychiatric symptoms and functional impairment.
- Patients often are unaware of the complete risks of psychotropics.
- Psychiatric symptoms are not always associated with a psychiatric disorder.
- Deprescribing can be performed safely and effectively.
- Deprescribing can be performed with the patient’s informed consent and agreement.
References
1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.
2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.
3. Bipolar Disord. 2016 Dec;18(8):684-91.
4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.
5. World Psychiatry. 2009 Jun;8(2):67-74.
6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
*This column was updated 1/11/2019.
In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.1 They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”1
In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants2 and mood stabilizers.3 The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.
Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
Overview of the case
Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.
In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”
When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.
After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.
Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
Initial visit
Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.
When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”
She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.
When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”
Assessment
I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.
Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.
She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.
Treatment plan
We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”
She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.
In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
Outcome
I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.
Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
Discussion
Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.4 There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.
Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.5 Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.6 Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
Take-home points
- Polypharmacy can lead to psychiatric symptoms and functional impairment.
- Patients often are unaware of the complete risks of psychotropics.
- Psychiatric symptoms are not always associated with a psychiatric disorder.
- Deprescribing can be performed safely and effectively.
- Deprescribing can be performed with the patient’s informed consent and agreement.
References
1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.
2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.
3. Bipolar Disord. 2016 Dec;18(8):684-91.
4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.
5. World Psychiatry. 2009 Jun;8(2):67-74.
6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
*This column was updated 1/11/2019.
Focus on symptoms over stories is detrimental to separated families
The horrors faced by migrant families forced to separate under the new U.S. “zero tolerance” policy continue to unfold. Tragic emblems of this policy include tapes of crying children and the reported suicide of a father who had been separated from his children.
A federal judge had issued an injunction requiring the reunification of thousands of families by July 26. Despite that deadline, hundreds of adults are no longer in the United States, and hundreds of children are scattered in shelters across the country.
In response to those events, mental health and medical organizations have released powerful statements. The American Psychological Association stated: “The administration’s policy ... is not only needless and cruel, it threatens the mental and physical health of both the children and their caregivers.” The American Medical Association issued a call asserting that separating children from their parents “will do great harm” and “create negative health impacts that will last an individual’s entire lifespan.” Meanwhile, the American Psychiatric Association’s president, Altha J. Stewart, MD, released a statement affirming that “any forced separation is highly stressful for children and can cause lifelong trauma, as well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder.”
As forensic experts who testify about the mental well-being of immigration detainees, we applaud those powerful and unambiguous messages from the leaders in our fields. Yet, their statements also underscore the limitations of our diagnostic models: Our field is caught in the difficult position of either applying ill-fitting diagnostic labels or overpathologizing a normal reaction to horrific circumstances. While not applying diagnoses potentially minimizes the enormous psychological burden of separation, diagnosing depression or PTSD as catchalls for suffering incorrectly defines the experience of many survivors of ongoing trauma.
Currently, most providers, in trying to communicate the effects of ongoing trauma, rely on the diagnoses of depression or PTSD. Both of these diagnoses, however, are problematic. The diagnosis of major depressive disorder, for example, is useful in communicating a loss of hope, and the inability to enjoy pleasurable things. However, depression is an episodic illness, often part of a larger chronic disorder.1 Depression often has a genetic-hereditary component. On the other hand, children suffering from childhood traumas often present lifelong and wide-ranging problems, which may be triggered by reminders but are not episodic. For example, children experiencing parental separation have difficulty forming attachments, which, in turn, leads to subsequent difficulty forming meaningful interpersonal relationships.
The diagnosis of PTSD is useful in communicating a myriad of possible symptoms, which may accompany the trauma. However, PTSD implies a traumatic event as described in criteria A of the DSM-5: “exposure to actual or threatened death, serious injury, or sexual violence.” As such, PTSD poorly encompasses the wide array of smaller yet repetitive traumas experienced by victims of ongoing trauma, such as those youth separated from their parents at the U.S. border. Furthermore, PTSD is a disorder with specific symptoms that, based on a vast body of research,2,3 inadequately describes the multitude of interpersonal, psychological, and physical consequences associated with the type of trauma caused by family separations.
Our understanding of the long-term sequelae of childhood trauma has been greatly influenced by the adverse childhood experiences (ACE) study. The ACE study, one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being, collected the life histories of more than 17,000 patients in a collaborative effort between the Centers for Disease Control and Prevention and Kaiser Permanente’s Health Appraisal Clinic.
The ACE study identified 10 forms of childhood trauma, including: abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes such as depression, suicide attempts, and engagement in high-risk behaviors, as well as significant medical consequences, including higher incidence of heart disease, diabetes, and stroke. Ultimately, having four or more ACEs was associated with early death.
In response to the emerging body of research on childhood trauma, various terms, including complex trauma, type-II trauma, and complex PTSD, have entered our professional lexicon as a means of communicating the wide-ranging consequences of developmental trauma. On the one hand, the less defined and rigid nature of these terms permits mental health providers to develop a rich narrative of a patient’s background, encompassing the patient’s behavior, character, and symptoms. However, the absence of formal terminology also has its drawbacks: Courts and juries have grown accustomed to diagnoses, labels, and syndromes. Most forensic mental health providers who testify about developmental trauma in court can predict the question: “So doctor, you are saying that the individual’s presentation is not severe enough to be considered PTSD, am I correct?” Disorders justify treatment, can explain disability, and warrant empathy; concomitantly, “complex trauma” runs the risk of being considered an academic explanation for trauma victims’ lifelong problems, rather than a societal failure that merits care.
Recognizing the limitations of our current diagnoses, the forthcoming update to the International Classification of Diseases (ICD-11) will add a new category: complex PTSD. The ICD-11 will attempt to widen the concept of trauma to include “conditions of prolonged adversity, in the form of sustained, repeated, or multiple forms of traumatic exposure.” Trauma exposure examples include genocide campaigns, childhood sexual abuse, child soldiering, severe domestic violence, torture, or slavery. The ICD-11 also expands our understanding of the consequences of trauma to include “affective dysregulation,” “negative self-concept,” and “disturbances in relationships” as part of a concept called “disturbances in self-organization.” Those are important steps in acknowledging the consequences of different forms of trauma as well as noticing a richer array of damages from those incidents.4
While the World Health Organization’s latest iteration of the ICD takes an important step in widening the scope of our diagnostic tools, we are cognizant that our field’s obsessional search for diagnoses, labels, and nomenclature reinforces a detrimental focus on symptoms over stories. However, as forensic mental health providers, we also are keenly aware that a failure to adopt common definitions impedes forensic evaluations, patient advocacy, public policy, and most importantly, patient care.
In the end, we have trained society to understand pathology through narrow lenses, and therefore, . So, despite the limitations of labels, let’s be encouraged by the World Health Organization’s efforts and continue in that direction.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is a licensed clinical and forensic psychologist in San Diego. Her practice consists of conducting forensic psychological evaluations for the courts with children, adolescents, and adults. Dr. Lehman has been qualified as an expert witness in California as well as in the federal courts. She previously was a supervisor at Sharper Future, a forensic rehabilitation program, and previously served as an adjunct faculty member at Alliant International University, San Diego. Dr. Lehman can be reached at fran@lehmanforensicpsych.com.
References
1. Am J Psychiatry. 2000 Sep;157(9):1501-4.
2. Psychiatr Ann. 2005;35(5):390-8.
3. Psychiatr Ann. 2005;35(5):401-8.
4. Eur J Psychotraumatol. 2018 Jan 15. doi: 10.1080/20008198.2017.1418103.
The horrors faced by migrant families forced to separate under the new U.S. “zero tolerance” policy continue to unfold. Tragic emblems of this policy include tapes of crying children and the reported suicide of a father who had been separated from his children.
A federal judge had issued an injunction requiring the reunification of thousands of families by July 26. Despite that deadline, hundreds of adults are no longer in the United States, and hundreds of children are scattered in shelters across the country.
In response to those events, mental health and medical organizations have released powerful statements. The American Psychological Association stated: “The administration’s policy ... is not only needless and cruel, it threatens the mental and physical health of both the children and their caregivers.” The American Medical Association issued a call asserting that separating children from their parents “will do great harm” and “create negative health impacts that will last an individual’s entire lifespan.” Meanwhile, the American Psychiatric Association’s president, Altha J. Stewart, MD, released a statement affirming that “any forced separation is highly stressful for children and can cause lifelong trauma, as well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder.”
As forensic experts who testify about the mental well-being of immigration detainees, we applaud those powerful and unambiguous messages from the leaders in our fields. Yet, their statements also underscore the limitations of our diagnostic models: Our field is caught in the difficult position of either applying ill-fitting diagnostic labels or overpathologizing a normal reaction to horrific circumstances. While not applying diagnoses potentially minimizes the enormous psychological burden of separation, diagnosing depression or PTSD as catchalls for suffering incorrectly defines the experience of many survivors of ongoing trauma.
Currently, most providers, in trying to communicate the effects of ongoing trauma, rely on the diagnoses of depression or PTSD. Both of these diagnoses, however, are problematic. The diagnosis of major depressive disorder, for example, is useful in communicating a loss of hope, and the inability to enjoy pleasurable things. However, depression is an episodic illness, often part of a larger chronic disorder.1 Depression often has a genetic-hereditary component. On the other hand, children suffering from childhood traumas often present lifelong and wide-ranging problems, which may be triggered by reminders but are not episodic. For example, children experiencing parental separation have difficulty forming attachments, which, in turn, leads to subsequent difficulty forming meaningful interpersonal relationships.
The diagnosis of PTSD is useful in communicating a myriad of possible symptoms, which may accompany the trauma. However, PTSD implies a traumatic event as described in criteria A of the DSM-5: “exposure to actual or threatened death, serious injury, or sexual violence.” As such, PTSD poorly encompasses the wide array of smaller yet repetitive traumas experienced by victims of ongoing trauma, such as those youth separated from their parents at the U.S. border. Furthermore, PTSD is a disorder with specific symptoms that, based on a vast body of research,2,3 inadequately describes the multitude of interpersonal, psychological, and physical consequences associated with the type of trauma caused by family separations.
Our understanding of the long-term sequelae of childhood trauma has been greatly influenced by the adverse childhood experiences (ACE) study. The ACE study, one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being, collected the life histories of more than 17,000 patients in a collaborative effort between the Centers for Disease Control and Prevention and Kaiser Permanente’s Health Appraisal Clinic.
The ACE study identified 10 forms of childhood trauma, including: abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes such as depression, suicide attempts, and engagement in high-risk behaviors, as well as significant medical consequences, including higher incidence of heart disease, diabetes, and stroke. Ultimately, having four or more ACEs was associated with early death.
In response to the emerging body of research on childhood trauma, various terms, including complex trauma, type-II trauma, and complex PTSD, have entered our professional lexicon as a means of communicating the wide-ranging consequences of developmental trauma. On the one hand, the less defined and rigid nature of these terms permits mental health providers to develop a rich narrative of a patient’s background, encompassing the patient’s behavior, character, and symptoms. However, the absence of formal terminology also has its drawbacks: Courts and juries have grown accustomed to diagnoses, labels, and syndromes. Most forensic mental health providers who testify about developmental trauma in court can predict the question: “So doctor, you are saying that the individual’s presentation is not severe enough to be considered PTSD, am I correct?” Disorders justify treatment, can explain disability, and warrant empathy; concomitantly, “complex trauma” runs the risk of being considered an academic explanation for trauma victims’ lifelong problems, rather than a societal failure that merits care.
Recognizing the limitations of our current diagnoses, the forthcoming update to the International Classification of Diseases (ICD-11) will add a new category: complex PTSD. The ICD-11 will attempt to widen the concept of trauma to include “conditions of prolonged adversity, in the form of sustained, repeated, or multiple forms of traumatic exposure.” Trauma exposure examples include genocide campaigns, childhood sexual abuse, child soldiering, severe domestic violence, torture, or slavery. The ICD-11 also expands our understanding of the consequences of trauma to include “affective dysregulation,” “negative self-concept,” and “disturbances in relationships” as part of a concept called “disturbances in self-organization.” Those are important steps in acknowledging the consequences of different forms of trauma as well as noticing a richer array of damages from those incidents.4
While the World Health Organization’s latest iteration of the ICD takes an important step in widening the scope of our diagnostic tools, we are cognizant that our field’s obsessional search for diagnoses, labels, and nomenclature reinforces a detrimental focus on symptoms over stories. However, as forensic mental health providers, we also are keenly aware that a failure to adopt common definitions impedes forensic evaluations, patient advocacy, public policy, and most importantly, patient care.
In the end, we have trained society to understand pathology through narrow lenses, and therefore, . So, despite the limitations of labels, let’s be encouraged by the World Health Organization’s efforts and continue in that direction.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is a licensed clinical and forensic psychologist in San Diego. Her practice consists of conducting forensic psychological evaluations for the courts with children, adolescents, and adults. Dr. Lehman has been qualified as an expert witness in California as well as in the federal courts. She previously was a supervisor at Sharper Future, a forensic rehabilitation program, and previously served as an adjunct faculty member at Alliant International University, San Diego. Dr. Lehman can be reached at fran@lehmanforensicpsych.com.
References
1. Am J Psychiatry. 2000 Sep;157(9):1501-4.
2. Psychiatr Ann. 2005;35(5):390-8.
3. Psychiatr Ann. 2005;35(5):401-8.
4. Eur J Psychotraumatol. 2018 Jan 15. doi: 10.1080/20008198.2017.1418103.
The horrors faced by migrant families forced to separate under the new U.S. “zero tolerance” policy continue to unfold. Tragic emblems of this policy include tapes of crying children and the reported suicide of a father who had been separated from his children.
A federal judge had issued an injunction requiring the reunification of thousands of families by July 26. Despite that deadline, hundreds of adults are no longer in the United States, and hundreds of children are scattered in shelters across the country.
In response to those events, mental health and medical organizations have released powerful statements. The American Psychological Association stated: “The administration’s policy ... is not only needless and cruel, it threatens the mental and physical health of both the children and their caregivers.” The American Medical Association issued a call asserting that separating children from their parents “will do great harm” and “create negative health impacts that will last an individual’s entire lifespan.” Meanwhile, the American Psychiatric Association’s president, Altha J. Stewart, MD, released a statement affirming that “any forced separation is highly stressful for children and can cause lifelong trauma, as well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder.”
As forensic experts who testify about the mental well-being of immigration detainees, we applaud those powerful and unambiguous messages from the leaders in our fields. Yet, their statements also underscore the limitations of our diagnostic models: Our field is caught in the difficult position of either applying ill-fitting diagnostic labels or overpathologizing a normal reaction to horrific circumstances. While not applying diagnoses potentially minimizes the enormous psychological burden of separation, diagnosing depression or PTSD as catchalls for suffering incorrectly defines the experience of many survivors of ongoing trauma.
Currently, most providers, in trying to communicate the effects of ongoing trauma, rely on the diagnoses of depression or PTSD. Both of these diagnoses, however, are problematic. The diagnosis of major depressive disorder, for example, is useful in communicating a loss of hope, and the inability to enjoy pleasurable things. However, depression is an episodic illness, often part of a larger chronic disorder.1 Depression often has a genetic-hereditary component. On the other hand, children suffering from childhood traumas often present lifelong and wide-ranging problems, which may be triggered by reminders but are not episodic. For example, children experiencing parental separation have difficulty forming attachments, which, in turn, leads to subsequent difficulty forming meaningful interpersonal relationships.
The diagnosis of PTSD is useful in communicating a myriad of possible symptoms, which may accompany the trauma. However, PTSD implies a traumatic event as described in criteria A of the DSM-5: “exposure to actual or threatened death, serious injury, or sexual violence.” As such, PTSD poorly encompasses the wide array of smaller yet repetitive traumas experienced by victims of ongoing trauma, such as those youth separated from their parents at the U.S. border. Furthermore, PTSD is a disorder with specific symptoms that, based on a vast body of research,2,3 inadequately describes the multitude of interpersonal, psychological, and physical consequences associated with the type of trauma caused by family separations.
Our understanding of the long-term sequelae of childhood trauma has been greatly influenced by the adverse childhood experiences (ACE) study. The ACE study, one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being, collected the life histories of more than 17,000 patients in a collaborative effort between the Centers for Disease Control and Prevention and Kaiser Permanente’s Health Appraisal Clinic.
The ACE study identified 10 forms of childhood trauma, including: abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes such as depression, suicide attempts, and engagement in high-risk behaviors, as well as significant medical consequences, including higher incidence of heart disease, diabetes, and stroke. Ultimately, having four or more ACEs was associated with early death.
In response to the emerging body of research on childhood trauma, various terms, including complex trauma, type-II trauma, and complex PTSD, have entered our professional lexicon as a means of communicating the wide-ranging consequences of developmental trauma. On the one hand, the less defined and rigid nature of these terms permits mental health providers to develop a rich narrative of a patient’s background, encompassing the patient’s behavior, character, and symptoms. However, the absence of formal terminology also has its drawbacks: Courts and juries have grown accustomed to diagnoses, labels, and syndromes. Most forensic mental health providers who testify about developmental trauma in court can predict the question: “So doctor, you are saying that the individual’s presentation is not severe enough to be considered PTSD, am I correct?” Disorders justify treatment, can explain disability, and warrant empathy; concomitantly, “complex trauma” runs the risk of being considered an academic explanation for trauma victims’ lifelong problems, rather than a societal failure that merits care.
Recognizing the limitations of our current diagnoses, the forthcoming update to the International Classification of Diseases (ICD-11) will add a new category: complex PTSD. The ICD-11 will attempt to widen the concept of trauma to include “conditions of prolonged adversity, in the form of sustained, repeated, or multiple forms of traumatic exposure.” Trauma exposure examples include genocide campaigns, childhood sexual abuse, child soldiering, severe domestic violence, torture, or slavery. The ICD-11 also expands our understanding of the consequences of trauma to include “affective dysregulation,” “negative self-concept,” and “disturbances in relationships” as part of a concept called “disturbances in self-organization.” Those are important steps in acknowledging the consequences of different forms of trauma as well as noticing a richer array of damages from those incidents.4
While the World Health Organization’s latest iteration of the ICD takes an important step in widening the scope of our diagnostic tools, we are cognizant that our field’s obsessional search for diagnoses, labels, and nomenclature reinforces a detrimental focus on symptoms over stories. However, as forensic mental health providers, we also are keenly aware that a failure to adopt common definitions impedes forensic evaluations, patient advocacy, public policy, and most importantly, patient care.
In the end, we have trained society to understand pathology through narrow lenses, and therefore, . So, despite the limitations of labels, let’s be encouraged by the World Health Organization’s efforts and continue in that direction.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is a licensed clinical and forensic psychologist in San Diego. Her practice consists of conducting forensic psychological evaluations for the courts with children, adolescents, and adults. Dr. Lehman has been qualified as an expert witness in California as well as in the federal courts. She previously was a supervisor at Sharper Future, a forensic rehabilitation program, and previously served as an adjunct faculty member at Alliant International University, San Diego. Dr. Lehman can be reached at fran@lehmanforensicpsych.com.
References
1. Am J Psychiatry. 2000 Sep;157(9):1501-4.
2. Psychiatr Ann. 2005;35(5):390-8.
3. Psychiatr Ann. 2005;35(5):401-8.
4. Eur J Psychotraumatol. 2018 Jan 15. doi: 10.1080/20008198.2017.1418103.
Homelessness: A need for better care
In 1946, Psychiatrist Viktor Frankl postulated in “Man’s Search for Meaning” that the expected reaction to being placed in a concentration camp was dehumanization, apathy, and despair. The placement of a person in such a desolate environment, anticipating death, and seeing the affliction of horror, was believed to lead to hopelessness and mental illness. Facing such circumstances, Dr. Frankl advised finding a purpose as a means to stay mentally and physically alive.
As contemporary psychiatrists, we see ourselves confronted with a different kind of challenge. Modern society has left more than a half-million of our fellow Americans on the streets, homeless, and with little connection to the rest of society. Despite their isolation, their paths merge with ours in an array of settings, namely mental health services in emergency departments, community clinics, and local correctional institutions. Nearly all psychiatrists have worked with a homeless patient at some point in their careers. The connection between mental illness and homelessness may be apparent to some, but we remain perplexed and propose more questions than answers.
What is the expected reaction to homelessness?
How might a homeless person describe his fears? “I don’t want to go to the emergency room, doc; these are all the belongings I have, and I have nowhere safe to store them. I have to carry a knife for protection despite the fact that it is illegal. I used to have a circle of support, but my ‘friends’ stole from me, and now I don’t trust anyone. I don’t like to be around a lot of people; I’ve seen some people do really horrible things on the streets that I can’t unsee. Sometimes, I think the cops enjoy arresting me; I wonder if it helps their quotas.” Are those concerns a sign of an anxiety disorder or even paranoia? Or is it how most people would respond if they were placed in similar situations?
How might a homeless person describe her mood? “I have no home. I have not seen my family in a decade. I am so disconnected from society that I do not know who the president is, or what is the date. Nobody has shaken my hand in years.” Yet, we expect that person to possibly narrow and codify her suffering with an adjective on a Likert scale, or even a visual analog scale of mood with a happy or a frowny face. We assume that their mood can even be narrowed to an emoji or a label, despite their complex circumstances.
When asked about social history, we often hear responses such as, “I have no income. I tried to get a job, but it was too hard to maintain my hygiene and transportation, so I quit. I applied for disability once, and I was denied. I want to work, but when you’ve been on the streets this long it’s hard. I mean … look at me. I applied for affordable housing twice, but I didn’t get it because I’ve been evicted in the last 5 years. The only time I had stable housing for an extended period of time in the last 10 years was when I went to jail for trespassing. I want to live, but I can’t go on like this. I think people would be better off without me if I was gone. Heck, maybe they wouldn’t even notice.” Would we permit a patient like this to be heard in a safe and nonconfrontational environment? Do they meet criteria for grave disability and/or danger to self? Or are they doing the best they can to get their needs met in a broken system?
Our clinical experience has taught us that the homeless population suffers from many of the same symptoms as those of patients with mental illness, independent of a diagnosis. Careful examination of their lives can often explain these expected reactions better than contextualizing them through pathological or diagnostic lenses.
Should homelessness alone be a criterion for mental health treatment?
Despite the enormous challenges facing the homeless population, many are seen in our clinics hopeful and endorsing a fair mood. Many are polite and answer questions in an attempt to diminish the burden they feel they impose on others, including the medical system. Many display strong resiliency and find ways to cope, relate, and find meaning despite their challenging circumstances. Yet, many also come to us suffering and seeking assistance.
We routinely see the distress and hopelessness in our patients suffering from homelessness. We think that psychiatry is capable of softening those daily traumas using supportive therapy. We think that psychiatry is capable of positively challenging the despondency by activating meaning and purpose, as suggested by Dr. Frankl. While those are not typical interventions in modern psychiatry, they are established and validated. By considering homelessness in and of itself a criterion for mental health treatment, we can begin to address those challenges, and engage in alternative, longer lasting treatment considerations.
How to proceed?
Though the answer for caring for the homeless may not be in psychopharmacology, we think that psychiatry could enhance the care of the homeless by pursuit of two main goals.
The first is to advocate for access to mental health services for all homeless persons who desire it, even those who do not meet criteria for a DSM disorder. This charade we are forced to play with insurance companies and community organizations requiring the presence of a “disorder” to justify supportive therapy and/or occasional use of a crisis house bed does not appear warranted. While we understand that resources are limited, we do not think that homeless persons who are in need of care, but do not meet criteria for a DSM disorder, are any less worthy.
The second goal is to advocate for housing first initiatives that incorporate comprehensive supportive services into their facilities. While we acknowledge the problems that can arise by forcing programs to accept clients, we do not see how mental health treatment can be done adequately without an opportunity for housing. Psychiatry must acknowledge that this social determinant of health takes priority over medication adherence, drug use, the ability to fill out forms, and even symptomatology. Sometimes, medications aren’t even necessary – we’ve worked with homeless patients who present initially with insomnia, depression, and anxiety, and as soon as they get stable housing, these symptoms resolve. In these situations, social interventions are more sensical than medication management. The social nature of homelessness should not propel psychiatry to focus its efforts on the biological side of its specialty; it should be seen as an opportunity for us to develop skills in advocacy and lead, or at least support, interventions that target the social determinants of health.
Under our current medical model, as psychiatrists, we understand that our role is to diagnose, and then treat the diagnosed disorder. Homelessness brings a unique challenge; it is a factor, not based on biology, that can cause severe psychiatric symptomatology with or without the presence of a DSM disorder. We worry that current constructs of mental health narrow our reach and inhibit our potential benefit to society. We hope to encourage psychiatry in embracing public health interventions such as housing first and remembering the value of psychological interventions when working with this vulnerable population.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including the reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com. Dr. Janowsky is a combined resident in family medicine and psychiatry at the University of California, San Diego. She spends most of her clinical time at St. Vincent de Paul Family Health Center, a clinic that primarily serves the homeless. Her interests include disease prevention, wellness promotion, and behavioral interventions for chronic disease management. Outside of work, you can find her recharging her batteries via yoga, musical meditation, hiking, beach journaling, and spending time with loved ones.
In 1946, Psychiatrist Viktor Frankl postulated in “Man’s Search for Meaning” that the expected reaction to being placed in a concentration camp was dehumanization, apathy, and despair. The placement of a person in such a desolate environment, anticipating death, and seeing the affliction of horror, was believed to lead to hopelessness and mental illness. Facing such circumstances, Dr. Frankl advised finding a purpose as a means to stay mentally and physically alive.
As contemporary psychiatrists, we see ourselves confronted with a different kind of challenge. Modern society has left more than a half-million of our fellow Americans on the streets, homeless, and with little connection to the rest of society. Despite their isolation, their paths merge with ours in an array of settings, namely mental health services in emergency departments, community clinics, and local correctional institutions. Nearly all psychiatrists have worked with a homeless patient at some point in their careers. The connection between mental illness and homelessness may be apparent to some, but we remain perplexed and propose more questions than answers.
What is the expected reaction to homelessness?
How might a homeless person describe his fears? “I don’t want to go to the emergency room, doc; these are all the belongings I have, and I have nowhere safe to store them. I have to carry a knife for protection despite the fact that it is illegal. I used to have a circle of support, but my ‘friends’ stole from me, and now I don’t trust anyone. I don’t like to be around a lot of people; I’ve seen some people do really horrible things on the streets that I can’t unsee. Sometimes, I think the cops enjoy arresting me; I wonder if it helps their quotas.” Are those concerns a sign of an anxiety disorder or even paranoia? Or is it how most people would respond if they were placed in similar situations?
How might a homeless person describe her mood? “I have no home. I have not seen my family in a decade. I am so disconnected from society that I do not know who the president is, or what is the date. Nobody has shaken my hand in years.” Yet, we expect that person to possibly narrow and codify her suffering with an adjective on a Likert scale, or even a visual analog scale of mood with a happy or a frowny face. We assume that their mood can even be narrowed to an emoji or a label, despite their complex circumstances.
When asked about social history, we often hear responses such as, “I have no income. I tried to get a job, but it was too hard to maintain my hygiene and transportation, so I quit. I applied for disability once, and I was denied. I want to work, but when you’ve been on the streets this long it’s hard. I mean … look at me. I applied for affordable housing twice, but I didn’t get it because I’ve been evicted in the last 5 years. The only time I had stable housing for an extended period of time in the last 10 years was when I went to jail for trespassing. I want to live, but I can’t go on like this. I think people would be better off without me if I was gone. Heck, maybe they wouldn’t even notice.” Would we permit a patient like this to be heard in a safe and nonconfrontational environment? Do they meet criteria for grave disability and/or danger to self? Or are they doing the best they can to get their needs met in a broken system?
Our clinical experience has taught us that the homeless population suffers from many of the same symptoms as those of patients with mental illness, independent of a diagnosis. Careful examination of their lives can often explain these expected reactions better than contextualizing them through pathological or diagnostic lenses.
Should homelessness alone be a criterion for mental health treatment?
Despite the enormous challenges facing the homeless population, many are seen in our clinics hopeful and endorsing a fair mood. Many are polite and answer questions in an attempt to diminish the burden they feel they impose on others, including the medical system. Many display strong resiliency and find ways to cope, relate, and find meaning despite their challenging circumstances. Yet, many also come to us suffering and seeking assistance.
We routinely see the distress and hopelessness in our patients suffering from homelessness. We think that psychiatry is capable of softening those daily traumas using supportive therapy. We think that psychiatry is capable of positively challenging the despondency by activating meaning and purpose, as suggested by Dr. Frankl. While those are not typical interventions in modern psychiatry, they are established and validated. By considering homelessness in and of itself a criterion for mental health treatment, we can begin to address those challenges, and engage in alternative, longer lasting treatment considerations.
How to proceed?
Though the answer for caring for the homeless may not be in psychopharmacology, we think that psychiatry could enhance the care of the homeless by pursuit of two main goals.
The first is to advocate for access to mental health services for all homeless persons who desire it, even those who do not meet criteria for a DSM disorder. This charade we are forced to play with insurance companies and community organizations requiring the presence of a “disorder” to justify supportive therapy and/or occasional use of a crisis house bed does not appear warranted. While we understand that resources are limited, we do not think that homeless persons who are in need of care, but do not meet criteria for a DSM disorder, are any less worthy.
The second goal is to advocate for housing first initiatives that incorporate comprehensive supportive services into their facilities. While we acknowledge the problems that can arise by forcing programs to accept clients, we do not see how mental health treatment can be done adequately without an opportunity for housing. Psychiatry must acknowledge that this social determinant of health takes priority over medication adherence, drug use, the ability to fill out forms, and even symptomatology. Sometimes, medications aren’t even necessary – we’ve worked with homeless patients who present initially with insomnia, depression, and anxiety, and as soon as they get stable housing, these symptoms resolve. In these situations, social interventions are more sensical than medication management. The social nature of homelessness should not propel psychiatry to focus its efforts on the biological side of its specialty; it should be seen as an opportunity for us to develop skills in advocacy and lead, or at least support, interventions that target the social determinants of health.
Under our current medical model, as psychiatrists, we understand that our role is to diagnose, and then treat the diagnosed disorder. Homelessness brings a unique challenge; it is a factor, not based on biology, that can cause severe psychiatric symptomatology with or without the presence of a DSM disorder. We worry that current constructs of mental health narrow our reach and inhibit our potential benefit to society. We hope to encourage psychiatry in embracing public health interventions such as housing first and remembering the value of psychological interventions when working with this vulnerable population.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including the reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com. Dr. Janowsky is a combined resident in family medicine and psychiatry at the University of California, San Diego. She spends most of her clinical time at St. Vincent de Paul Family Health Center, a clinic that primarily serves the homeless. Her interests include disease prevention, wellness promotion, and behavioral interventions for chronic disease management. Outside of work, you can find her recharging her batteries via yoga, musical meditation, hiking, beach journaling, and spending time with loved ones.
In 1946, Psychiatrist Viktor Frankl postulated in “Man’s Search for Meaning” that the expected reaction to being placed in a concentration camp was dehumanization, apathy, and despair. The placement of a person in such a desolate environment, anticipating death, and seeing the affliction of horror, was believed to lead to hopelessness and mental illness. Facing such circumstances, Dr. Frankl advised finding a purpose as a means to stay mentally and physically alive.
As contemporary psychiatrists, we see ourselves confronted with a different kind of challenge. Modern society has left more than a half-million of our fellow Americans on the streets, homeless, and with little connection to the rest of society. Despite their isolation, their paths merge with ours in an array of settings, namely mental health services in emergency departments, community clinics, and local correctional institutions. Nearly all psychiatrists have worked with a homeless patient at some point in their careers. The connection between mental illness and homelessness may be apparent to some, but we remain perplexed and propose more questions than answers.
What is the expected reaction to homelessness?
How might a homeless person describe his fears? “I don’t want to go to the emergency room, doc; these are all the belongings I have, and I have nowhere safe to store them. I have to carry a knife for protection despite the fact that it is illegal. I used to have a circle of support, but my ‘friends’ stole from me, and now I don’t trust anyone. I don’t like to be around a lot of people; I’ve seen some people do really horrible things on the streets that I can’t unsee. Sometimes, I think the cops enjoy arresting me; I wonder if it helps their quotas.” Are those concerns a sign of an anxiety disorder or even paranoia? Or is it how most people would respond if they were placed in similar situations?
How might a homeless person describe her mood? “I have no home. I have not seen my family in a decade. I am so disconnected from society that I do not know who the president is, or what is the date. Nobody has shaken my hand in years.” Yet, we expect that person to possibly narrow and codify her suffering with an adjective on a Likert scale, or even a visual analog scale of mood with a happy or a frowny face. We assume that their mood can even be narrowed to an emoji or a label, despite their complex circumstances.
When asked about social history, we often hear responses such as, “I have no income. I tried to get a job, but it was too hard to maintain my hygiene and transportation, so I quit. I applied for disability once, and I was denied. I want to work, but when you’ve been on the streets this long it’s hard. I mean … look at me. I applied for affordable housing twice, but I didn’t get it because I’ve been evicted in the last 5 years. The only time I had stable housing for an extended period of time in the last 10 years was when I went to jail for trespassing. I want to live, but I can’t go on like this. I think people would be better off without me if I was gone. Heck, maybe they wouldn’t even notice.” Would we permit a patient like this to be heard in a safe and nonconfrontational environment? Do they meet criteria for grave disability and/or danger to self? Or are they doing the best they can to get their needs met in a broken system?
Our clinical experience has taught us that the homeless population suffers from many of the same symptoms as those of patients with mental illness, independent of a diagnosis. Careful examination of their lives can often explain these expected reactions better than contextualizing them through pathological or diagnostic lenses.
Should homelessness alone be a criterion for mental health treatment?
Despite the enormous challenges facing the homeless population, many are seen in our clinics hopeful and endorsing a fair mood. Many are polite and answer questions in an attempt to diminish the burden they feel they impose on others, including the medical system. Many display strong resiliency and find ways to cope, relate, and find meaning despite their challenging circumstances. Yet, many also come to us suffering and seeking assistance.
We routinely see the distress and hopelessness in our patients suffering from homelessness. We think that psychiatry is capable of softening those daily traumas using supportive therapy. We think that psychiatry is capable of positively challenging the despondency by activating meaning and purpose, as suggested by Dr. Frankl. While those are not typical interventions in modern psychiatry, they are established and validated. By considering homelessness in and of itself a criterion for mental health treatment, we can begin to address those challenges, and engage in alternative, longer lasting treatment considerations.
How to proceed?
Though the answer for caring for the homeless may not be in psychopharmacology, we think that psychiatry could enhance the care of the homeless by pursuit of two main goals.
The first is to advocate for access to mental health services for all homeless persons who desire it, even those who do not meet criteria for a DSM disorder. This charade we are forced to play with insurance companies and community organizations requiring the presence of a “disorder” to justify supportive therapy and/or occasional use of a crisis house bed does not appear warranted. While we understand that resources are limited, we do not think that homeless persons who are in need of care, but do not meet criteria for a DSM disorder, are any less worthy.
The second goal is to advocate for housing first initiatives that incorporate comprehensive supportive services into their facilities. While we acknowledge the problems that can arise by forcing programs to accept clients, we do not see how mental health treatment can be done adequately without an opportunity for housing. Psychiatry must acknowledge that this social determinant of health takes priority over medication adherence, drug use, the ability to fill out forms, and even symptomatology. Sometimes, medications aren’t even necessary – we’ve worked with homeless patients who present initially with insomnia, depression, and anxiety, and as soon as they get stable housing, these symptoms resolve. In these situations, social interventions are more sensical than medication management. The social nature of homelessness should not propel psychiatry to focus its efforts on the biological side of its specialty; it should be seen as an opportunity for us to develop skills in advocacy and lead, or at least support, interventions that target the social determinants of health.
Under our current medical model, as psychiatrists, we understand that our role is to diagnose, and then treat the diagnosed disorder. Homelessness brings a unique challenge; it is a factor, not based on biology, that can cause severe psychiatric symptomatology with or without the presence of a DSM disorder. We worry that current constructs of mental health narrow our reach and inhibit our potential benefit to society. We hope to encourage psychiatry in embracing public health interventions such as housing first and remembering the value of psychological interventions when working with this vulnerable population.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including the reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com. Dr. Janowsky is a combined resident in family medicine and psychiatry at the University of California, San Diego. She spends most of her clinical time at St. Vincent de Paul Family Health Center, a clinic that primarily serves the homeless. Her interests include disease prevention, wellness promotion, and behavioral interventions for chronic disease management. Outside of work, you can find her recharging her batteries via yoga, musical meditation, hiking, beach journaling, and spending time with loved ones.