Psychiatry does not always have all the answers. However, the ability we develop over the years to introspect, to be self-aware, and to look at ourselves from the outside becomes one of our most significant personal gains on this journey. That, accompanied by the lessons learned through following the trajectories of the lives of people we treat, sometimes is all we need to navigate the sunrises and sunsets of our own lives.

Being a psychiatrist and a parent, assessing and learning about my own limitations, has been one of the most enriching and humbling experiences of my life.

Took me a while to find a teapot for five

The smaller one will make the tea too strong

But the teapot for five was still alright

Little more work to have the tea taste good

I don’t like that there is so much left over

I don’t like that I know I need a new teapot

While the one for five comes out for holidays

I don’t like that some days we are too tired for tea

and other days, it does not seem that important

I don’t like that the pot for two makes the tea taste right

 is a psychiatrist in private practice in McLean, Virginia.

Articles

How working with patients can help us navigate the sunrises and sunsets of our own lives.

Of Tea, Teapots, and Other Things

 was stuffed with clinical pearls, insights, and need-to-know info. As you pick up a plate at Thanksgiving, enjoy some of these articles.

A Role for Psychiatry in Understanding and Overcoming Vaccine Hesitancy

“I hope to inspire you to apply your understanding of the human psyche to the curious matter of people who are contracting a life-threatening infection because they are reluctant to heed the advice of their physicians and the public health community,” writes Steve Adelman, MD. Adelman talks about the “nocebo effect,” or the belief that some individuals have that an effective medical treatment will cause them harm. Placebos have the potential to cure, but nocebos can cause pain. Adelman recommends careful listening, psychosocial formulation, and precise communication to help patients and colleagues manage better in this challenging era of pseudo-information and reductionistic thinking.

 Editor in Chief—John J. Miller, MD—asks us to imagine the human brain as a mansion. We may have favorite rooms in the mansion, but others may find them outdated and in need of repair.

“I try to have an open mind when speaking to a friend, neighbor, or colleague whose views are in opposition to mine, realizing their room and window are based on their unique experiences. Sometimes it is hard when the truth seems so obvious to me,” said Miller.

He invites you to explore some rooms in the mansion that you have not visited before, and promises to do the same.

Cognitive/Neuropsychological Functioning and Suicidal Behavior: A Review of Research and Implications for Clinical Practice

Jerrold Pollak, PhD, invites you to learn to identify 3 patient groups who are characterized by elevated rates of suicidal behavior and cooccurring cognitive/neuropsychological impairment in this month’s Continuing Medical Education article. By increasing your familiarity with the indications for psychological/neuropsychological testing of patients with suicidal behavior and suspected or known cognitive/neuropsychological impairment, Pollak hopes to help enhance your appreciation of a good working knowledge of neurocognitive status in assessment and treatment planning with suicidal patients.

David N. Osser, MD, helps distinguish common challenging comorbidities that add to symptoms of bipolar disorder, including attention-deficit/hyperactivity disorder, sleep issues, anxiety, and posttraumatic stress disorder.

“Comorbidities in patients with bipolar disorder are the rule rather than the exception. Good clinical practice requires us to spend the time to complete a comprehensive evaluation to tease out the various comorbidities and then to treat each one appropriately,” said Osser.

Don’t miss all of these and more in the 

Cranberry sauce and clinical pearls: the most delicious of combos. Check out more of our November issue. 

No-Skip November: Don’t Miss These Articles

is an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine, Greenville. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

Being thankful, reflective, and hopeful...  

A Psychiatrist's Reflections for Thanksgiving

 was characterized as a pandemic, it was clear that older adults in general, and those with 

 (ADRD) in particular, would be severely impacted both directly by the virus and indirectly by the social consequences and responses.

 Now, approaching 2 years since SARS-CoV-2 emerged, we are starting to measure the impact of COVID-19 on older patients with cognitive impairment and ADRD. Further, we can begin to review neurobiological issues associated with COVID-19 in older adults, and consider how COVID-19 may contribute to cognitive impairment and future cases of dementia.

The demographics of COVID-19 cases have shifted over time, with older adults being most impacted early in the pandemic, and later waves involving younger individuals.

 Similarly, risk varied by setting, with an early wave of COVID-19 cases in congregate settings including nursing homes, retirement homes, and hospitals. These frequent and widespread outbreaks were associated with significant morbidity and mortality. Despite campaigns to vaccinate nursing home residents, they still account for a large proportion of the total deaths due to COVID-19.

The severity of COVID-19 spans the spectrum from asymptomatic carrier state to severe illness and death, with age being the strongest demographic risk factor for a more severe illness: Age has an exponential relationship with infection fatality rate, reaching 15% at age 85.

 Older adults with cognitive impairment are doubly at risk, with age and cognitive impairment independently contributing to illness severity.

 Cognitive impairment has been associated with double the risk of COVID-19 mortality in nursing homes.

 Even when controlling for residence in a nursing home, those with dementia had twice the risk of acquiring COVID-19.

We had anticipated that rates of behavioral and psychologic symptoms associated with dementia (BPSD) would increase as a result of indirect factors such as disruption to care, social isolation, and disruption to routine.

 Unfortunately, this has been borne out, with studies reporting increases in BPSD including anxiety, depression, insomnia, wandering, and agitation.

Alongside the risk of mortality, the pandemic is also affecting mental health negatively, both via the direct effect of the virus and indirectly via the massive disruption to society in response to the pandemic. Early and ongoing mental health consequences of the pandemic include increased rates of symptoms of depression, anxiety, substance use, and suicidal ideation. However, paradoxically, younger individuals may be more impacted than older ones.

 Similarly, while the pandemic may have increased BPSD in some individuals with dementia, this has not been universally true. For example, in New Brunswick, Canada, despite a marked reduction in family visits and periods of lockdown (mitigated by virtual visits and volunteer services), there was no change in rates of agitation, and a reduction in rates of depression among nursing home residents, with more than half of them having dementia.

The availability of safe and effective COVID-19 vaccines is thought to be a key element to ending the pandemic. Early on, in the context of limited supply, governments prioritized vaccination for high-risk groups such as the elderly and those living in long-term care (LTC) facilities. Thus, most individuals with dementia were prioritized for vaccination. For example, in Ontario, Canada, despite only 0.5% of the population living in LTC facilities, vaccination initially was reserved for LTC residents and health professionals when vaccines first became available in December 2019.

 By March 2020, more than 92% of LTC residents had received at least 1 dose of a COVID-19 vaccine, which was estimated to have reduced mortality by 96%.

 The recent approval by the US Food and Drug Administration of booster shots for older persons (ie, a third dose) may offer them further protection and also deepen current inequities when vaccination remains unavailable due to supply constraints in some jurisdictions.

COVID-19 is transmitted person to person via inhalation of respiratory droplets and their deposition on mucous membranes, and to a lesser extent by contaminated hands contacting mucous membranes.

 The virus enters cells via the angiotensin-converting enzyme 2 receptor, present not only in the respiratory and gastrointestinal tract but also in other organs, including the brain and blood vessels.

 Thus, COVID-19 can potentially lead to neuropathology via systemic and inflammatory indirect effects and by its direct action on the nervous system.

Although most cases of COVID-19 are classified as mild, severe cases occur in individuals of all ages, most commonly in older adults. Common acute symptoms include cough, fever, fatigue, headache, myalgias, and diarrhea.

 Symptoms can progress and involve hypoxemia and acute respiratory distress syndrome.

 In addition, injury to all organ systems due to severe inflammation, thromboembolic events, and neurologic complications can occur.

The neurologic consequences of severe COVID-19 are common and involve both the central nervous system (CNS) and peripheral nervous system (PNS) (

 Dizziness and headache are the most common CNS manifestations, which can also include cerebrovascular disease (eg, ischemic stroke, hemorrhage), ataxia, and seizure. Delirium is a common presentation of older adults with COVID-19; it has a very poor prognosis and is associated with permanent cognitive impairment.

 Anosmia and ageusia are the most common PNS manifestations.

 Common CNS and PNS Manifestations of COVID-19

Neurologic manifestations can occur within the first days of illness and persist months after hospital discharge.

 Isolating the virus in cerebrospinal fluid is rare.

 Cognitive impairment is a commonly reported symptom in survivors of severe COVID-19 at 60 days post discharge.

 Although research is needed to confirm the neuropsychiatric sequelae of COVID-19, a broad spectrum of neuropsychiatric symptoms have been reported, including headaches, sleep disorders, encephalopathy, myalgia, and ageusia.

 The term long COVID refers to the persistence of symptoms after the resolution of the acute infection, and a broad range of symptoms have been reported, including neuropsychiatric symptoms such as cognitive impairment, insomnia, impaired concentration, posttraumatic symptoms, and headache.

 Long COVID is not always associated with the severity of acute COVID-19 or risk factors for severe COVID-19, and it may involve multiple organ damage by other direct mechanisms.

 Long COVID is thought to be relatively common, but estimates of its prevalence vary widely depending on definition and time since infection. It may also depend on the SARS-CoV-2 genetic variant.

There is evidence for both structural and functional brain changes following COVID-19, and these changes may be associated with the neurologic symptoms of long COVID. Various studies have reported heterogenous findings. A recent systematic review summarizing the neuroimaging findings associated with COVID-19 in older adults reported widespread neuropathological issues typically associated with cerebrovascular damage, most consistently in white matter, brainstem, and frontotemporal cortical areas.

 A case-control study of patients who recovered from COVID-19 found hypometabolism in frontotemporal regions, which was associated with neurological symptoms.

 A study of United Kingdom Biobank participants by Douaud et al found changes in 394 individuals who had brain imaging before and after a COVID-19 infection, compared with 388 matched controls without a history of COVID-19. Among those who had survived COVID-19, Douaud et al identified reductions in grey matter in the left parahippocampal gyrus, left lateral orbitofrontal cortex, and left insula.

Although it is staggering that approximately 1 in 500 Americans has died of COVID-19, mortality is the tip of the iceberg. The Centers for Disease Control and Prevention estimates that as of May 29, 2021, there had been more than 100 million individuals with symptomatic COVID-19 in the United States, 10 million of them 65 years or older.

 The sequelae from severe COVID-19 are risk factors for dementia, and they may increase the growing number of individuals living with dementia. Understanding the specific contribution of a past COVID-19 infection on future risks of dementia will require longitudinal studies. These risks may be substantial given the cerebrovascular changes associated with past infection. During the next few years, post-COVID-19 issues may occur mostly in older adults. However, COVID-19 may also increase the risk of future cognitive impairment and dementia in younger individuals, because early life experiences and exposures contribute to the risk of dementia, as is the case in other risk factors for dementia such as low level of education or depression early in life. The magnitude of the current and future human, financial, and societal cost of COVID-19 is unknown, but certainly worrisome.

On the other hand, we expect that the pandemic will lead to numerous changes that benefit older adults. Specifically, the spotlight on nursing homes has revealed systemic flaws and inequities in many countries that now will be hard to ignore. The pivot to virtual care has spurred some innovation that may facilitate access to care going forward.

In our own experience, working at the Centre for Addiction in Mental Health in Toronto, we have had to pivot to providing care to older individuals despite multiple waves of COVID-19 cases in the community. Some of the changes in our practice and our environment will have long-lasting benefits. The heterogeneity of real-world experience, compared with averages often reported in research, is humbling. Some of our older patients have shown remarkable resilience through the pandemic and have adjusted their lifestyle to thrive during this time. Others have had their usual coping mechanisms totally disrupted and are suffering, needing additional mental health and social resources. In our geriatric mental health inpatient unit, technology (eg, internet-connected tablets) has been helpful to connect patients to family, activities, and entertainment. We have also noticed an improved access to specialist consultations with virtual care and additional physician-to-physician consultation options. In our outpatient setting, virtual care options introduced to reduce risk of COVID-19 have also reduced barriers for certain patients who prefer it or may have mobility issues.

The impact of the pandemic on older adults and those with dementia has been immense. Vaccination can dramatically reduce severe outcomes from COVID-19 in older adults. The indirect impact of the pandemic on individuals with dementia, such as isolation and disruption of care, can be pronounced, but they can also be mitigated. COVID-19 causes neurological damage that is not restricted to severe cases or older adults. A significant proportion of individuals infected by COVID-19 will experience long-term negative impact, including an increased risk of dementia. Research to better understand the neurobiology and the long-term neuropsychiatric impacts of COVID-19 is critical, as it will shift the understanding of the risk-benefit of population-level interventions to prevent COVID-19. The pandemic is not over. Efforts to protect everyone, including older adults, from COVID-19 are essential.

 is an assistant professor of psychiatry at the University of Toronto and a clinician scientist at the Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, in Toronto, Canada. 

 is an associate professor of psychiatry at the University of Toronto and chief of geriatric psychiatry at the Centre for Addiction and Mental Health. 

 is the Labatt Family Chair of the Department of Psychiatry in the Faculty of Medicine at the University of Toronto and a clinician scientist in the Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health.

Anticipating and mitigating the impact of the COVID-19 pandemic on Alzheimer’s disease and related dementias

2. Boehmer TK, DeVies J, Caruso E, et al. 

Changing age distribution of the COVID-19 pandemic – United States, May-August 2020

3. Panagiotou OA, Kosar CM, White EM, et al. 

Risk factors associated with all-cause 30-day mortality in nursing home residents with COVID-19

Nursing home care in crisis in the wake of COVID-19

5. Levin AT, Hanage WP, Owusu-Boaitey N, et al. 

Assessing the age specificity of infection fatality rates for COVID-19: systematic review, meta-analysis, and public policy implications

6. Tahira AC, Verjovski-Almeida S, Ferreira ST. 

Dementia is an age-independent risk factor for severity and death in COVID-19 inpatients

COVID-19 and dementia: analyses of risk, disparity, and outcomes from electronic health records in the US

Effectively caring for individuals with behavioral and psychological symptoms of dementia during the COVID-19 pandemic

9. Dellazizzo L, Léveillé N, Landry C, Dumais A. 

Systematic review on the mental health and treatment impacts of COVID-19 on neurocognitive disorders

10. Czeisler MÉ, Lane RI, Wiley JF, et al. 

Follow-up survey of US adult reports of mental health, substance use, and suicidal ideation during the COVID-19 pandemic, September 2020

11. McArthur C, Saari M, Heckman GA, et al. 

Evaluating the effect of COVID-19 pandemic lockdown on long-term care residents’ mental health: a data-driven approach in New Brunswick

12. Brown KA, Stall NM, Vanniyasingam T, et al. Early impact of Ontario’s COVID-19 vaccine rollout on long-term care home residents and health care workers. Science Table: COVID-19 Advisory for Ontario. March 8, 2021. Accessed October 5, 2021. 

https://covid19-sciencetable.ca/wp-content/uploads/2021/03/Science-Brief_LTC-and-Vaccine_20210308_version-1.1_published-1.pdf

13. Scientific brief: SARS-CoV-2 transmission. Centers for Disease Control and Prevention. Updated May 7, 2021. Accessed September 28, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/sars-cov-2-transmission.html

14. Hamming I, Timens W, Bulthuis MLC, et al. 

Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. a first step in understanding SARS pathogenesis

Long Covid – mechanisms, risk factors, and management

Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China

18. Marengoni A, Zucchelli A, Grande G, et al. 

The impact of delirium on outcomes for older adults hospitalised with COVID-19

19. Chopra V, Flanders SA, O’Malley M, et al. 

Sixty-day outcomes among patients hospitalized with COVID-19

20. García-Azorín D, Abildúa MJA, Aguirre MEE, et al; Spanish neuroCOVID registry group. 

Neurological presentations of COVID-19: findings from the Spanish Society of Neurology neuroCOVID-19 registry

21. Nalleballe K, Reddy Onteddu S, Sharma R, et al. 

Spectrum of neuropsychiatric manifestations in COVID-19

Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments

23. Manca R, De Marco M, Ince PG, Venneri A. 

Heterogeneity in regional damage detected by neuroimaging and neuropathological studies in older adults with COVID-19: a cognitive-neuroscience systematic review to inform the long-term impact of the virus on neurocognitive trajectories

24. Guedj E, Campion JY, Dudouet P, et al. 

F-FDG brain PET hypometabolism in patients with long COVID

25. Douaud G, Lee S, Alfaro-Almagro F, et al. 

Brain imaging before and after COVID-19 in UK Biobank

26. Estimated COVID-19 burden. Centers for Disease Control and Precention. Updated July 27, 2021. Accessed September 28, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/burden.html

How does COVID-19 contribute to cognitive impairment in older adults and future cases of dementia?

COVID-19, Cognition, and Dementias: What Role Has the Pandemic Played?

Richard P. Gerhardstein, MD, (Dick) was one of our Milwaukee local area’s unsung psychiatrists, but there is much to sing about as we view his life. He died on October 17, 2021 at the age of 89.

In Memoriam: A Mind at Home With the World

In Memoriam: Charles Atkins, MD, aka Caleb James

He practiced clinical psychiatry for 40 years, with a particular focus on addiction. He also did some administration as the Medical Director of the Milwaukee County Mental Health Center.

In his personal life, he had widespread interests and knowledge. Loving the outdoors, he left his mark on a noteworthy rock wall that he built with his sons on his property, which was also visible to the public. His ecological knowledge was conveyed on walks, where he recognized an invasive species, a special rose, or an interesting tree.

As if all of this was not enough of a contribution to society, the family requested that memorials be sent to RIP Medical Debt. Dick recognized and felt that medical debt was a particularly problematic American injustice and wanted to help that any way he could. Indeed, over 100 million Americans are struggling with medical debt. The RIP charity claims to have helped to abolish billions in debt, but indicates that there is so much more to do.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

Memorials for Richard P. Gerhardstein, MD, should be sent to RIP Medical Debt, as Gerhardstein felt medical debt was a particularly problematic American injustice. 

In Memoriam: Richard P. Gerhardstein, MD

Aducanumab’s recent approval by the US Food and Drug Administration (FDA) for Alzheimer disease has been controversial. In response, the American Academy of Neurology (AAN) issued a position statement for mental health professionals, covering decisions with patients and families regarding aducanumab in the treatment of Alzheimer disease, strongly recommending consent.

, yet since it has been approved by the FDA, patients are asking their doctors if this is an option for them,” said one of the authors, Winston Chiong, MD, PhD, of the University of California San Francisco and a member of the AAN’s Ethics, Law, and Humanities Committee. “This is a high-cost drug that was approved by the FDA without convincing evidence of benefits and with known harms.”

The AAN position statement stresses that it is ethically important to communicate that 

 does not restore cognitive function. Although aducanumab reduces beta-amyloid plaques that are markers of Alzheimer disease in the brain, it remains unclear whether beta-amyloid plaque reduction provides any meaningful benefits to patients. Additionally, there are insufficient grounds to warrant offering it to patients with moderate or advanced dementia, or to those without evidence of beta-amyloid in the brain.

“It is understandable why a new drug for Alzheimer disease generates so much interest, because while its approval has been controversial, it still offers a glimmer of hope to patients and their families,” said Orly Avitzur, MD, MBA, FAAN, President of the American Academy of Neurology. “By using ethical principles to create this position statement, the American Academy of Neurology aims to help neurologists and other physicians transparently counsel patients and their families with a goal of providing the highest quality patient-centered care.”

The position statement notes that there is a risk of amyloid-related imaging abnormalities with 

, including brain bleeds. During research, aducanumab was associated with brain inflammation and bleeds in a third of the individuals who received the FDA-approved dose. Physicians need to communicate potential adverse effects when discussing this treatment option with patients.

Another ethical concern the position statement noted is the absence of racial and ethnic diversity in the clinical trials of aducanumab. Minority populations are thus deprived of relevant information about the benefits and harms of the drug for their specific populations.

 may cause financial harm to patients receiving the drug, depending on how Medicare decides to address individual patient costs. With a price of $56,000 a year—not including costs of infusing the drug, repeated imaging, and medical management—aducanumab could end up costing patients and families significant amounts annually. The position statement recommends physicians discuss how full costs of treatment may not be covered by Medicare.

Helen Lavretsky, MD, MS, a professor in-residence in the Department of Psychiatry at the University of California, Los Angeles, and 

 editorial board member, concurred with the AAN. “I am very much in agreement with the very cautious statement that emphasizes the limited evidence for significant cognitive or functional improvement, the lack of promise to reverse or even slow Alzheimer disease progression, the very high cost of the drug and monitoring protocols, and the exuberant cost of the drug to the Medicare that would triple the cost of AD care, even if only 10% [of individuals] with Alzheimer disease receive the drug, along with the lack of data on long-term safety outcomes warrant a very careful approach and recommendation for the patients and families.”

“The decision should be made by doctors together with patients and [after] full disclosure of incurring costs of treatment, most often not covered by the insurances, that can only offer limited benefits for cognition along with high likelihood of brain inflammation, and complicated protocols for safety monitoring with costly expensive brain scans. The administration of the drug will also require collaborative care model between primary care and geriatric neurology and psychiatry,” said Lavretsky further.

Lavretsky also wished to draw attention to a viewpoint by Salloway and Cummings,

 who noted that the approval and implementation of aducanumab is justified and will open a new era in the treatment of Alzheimer disease.

The full statement is published in the online issue of 

1. Chiong W, Tolchin BD, Bonnie RJ, et al. Decisions with patients and families regarding aducanumab in Alzheimer disease, with recommendations for consent: AAN position statement. 

November 17, 2021. Accessed November 22, 2021. 

https://n.neurology.org/content/early/2021/11/17/WNL.0000000000013053

Aducanumab, amyloid lowering, and slowing of Alzheimer disease.

The American Academy of Neurology issued a position statement for mental health professionals, warning them to carefully discuss the benefits and known harms of aducanumab. 

Aducanumab: A Tentative Position

Thanksgiving Day has just passed, but that does not mean, of course, that we should stop being thankful. In fact, at its best, Thanksgiving reminds us to be more thankful in terms of gratitude.

Gratitude may be thought of as the essence of positive psychology and psychiatry. Why? Other than genetics, it seems to be the most important and powerful contributor to happiness and positive relationships.

Thankfully, gratitude is an attitude that can also be developed. So, even if your Thanksgiving was tarnished by family conflict, loneliness, or something else, you can still be grateful for what you had, have, and hopefully will have.

But how do you get to such ongoing gratitude if you do not have it already? Find some ritual gratitude practice. It also would not be out of the question to be grateful and compassionate to yourself for challenging achievements.

 article “Giving thanks during a pandemic: ‘We learn to appreciate things when we lose them,’” conveyed, difficult times are one with Thanksgiving Day historically.

 It was first celebrated in our country after a harsh winter and death of many pilgrims. It became a national holiday during our Civil War. The current date of our Thanksgiving holiday came to be in the middle of the Depression.

We know that for our patients, grabbing gratitude may be an even greater challenge. Depression in particular increase negativity, which is where the positive reframing of cognitive behavioral therapy comes in.

In this spirit of gratitude, let me in the very least thank anybody who reads this and especially those who comment, the editors who helped post it, 

 for their appreciation of all that goes into psychiatry, and, as always—and most importantly—my family and friends.

1. della Cava M. Giving thanks during a pandemic: ‘We learn to appreciate things when we lose them.’ 

 November 22, 2021. Accessed November 29, 2021. 

https://www.usatoday.com/story/life/health-wellness/2021/11/22/thanksgiving-pandemic-era-gratitude/8658809002/

Gratitude: the essence of psychology and psychiatry. 

Thanksgiving and Thankfulness

My uncle, who has schizophrenia, was shot by police in summer 2000. After decades of living in the streets, jail cells, and hospital beds across the country, he had finally procured housing and was living in an apartment alone. He was also disconnected from any meaningful mental health services, off his psychiatric medication, and spiraling into a paranoid psychotic state. As my uncle was noticeably sick and carrying a knife, his apartment manager called 911 after seeing my uncle staring out of his window, spinning the blade in his hand. Although the apartment manager felt threatened, he also knew that my uncle had schizophrenia and gave this information in his 911 call.

Two policemen responded, and after a few minutes of talking through the doorway, my uncle opened the door, and they muscled their way in. He backed into his kitchen and was pepper-sprayed by one of the officers. Depending on who is asked, he either dropped the knife or threw it in their direction. Either way, as soon as the knife left his hand, the other officer shot him. My aunt, tasked with cleaning up the horrific scene, remembers how the blood on the linoleum floor stood in stark contrast to the spotless apartment that my uncle otherwise kept. Decades later, when recounting the familial pain, it is chilling images like these that most vividly remain.

“I’m not a quitter, Sam,” my uncle reassures me with his smoky voice, not only about surviving being shot, but also regarding his recent hospitalization with COVID-19. With a twisted sense of justice, after recovering from multiple surgeries and a lengthy medical hospitalization, my uncle was ultimately arrested for assault against a police officer and spent the next several years between prison and state forensic psychiatric facilities. Framed as both the victim and the perpetuator of what is ostensibly the crime of having a serious mental illness, he embodies the violent and criminalized fate of our brothers and sisters suffering from these diseases. Although tragic, I have little doubt that had my uncle been black or brown, the police would not have stopped with 1 bullet and the outcome would have been deadlier.

Approximately 25% of fatal police shootings involve someone in a mental health crisis.

 Police encounters are 16 times more likely to result in someone’s death if the individual has an untreated mental illness.

 This risk is highest among Black men, who, even without mental illness, have a 1 in 1000 chance of being killed by police over their lifetime.

 Decades of relying on police as mental health first responders have led to generations of communities suffering unnecessary prison time, injuries, and death.

Motivated to help people with struggles similar to those of my uncle, I am now in my third year of psychiatry residency training in Brooklyn. I regularly hear from families who fear police response to mental health emergencies. Crippled by the horror stories they have heeded or lived, these families wait until their son or daughter’s illness becomes more life-threatening than calling for help. It is an impossible situation, in which the structural violence has not just eroded the trust in our health care system—it has prevented people from getting treatment at all.

This narrative, however, may be changing. Large cities like New York City, Pittsburgh, San Francisco, and others are starting pilot programs where mobile crisis teams comprised of mental health professionals will be dispatched as first responders to behavioral health calls instead of police.

 As a result of the American Rescue Plan, the Centers for Medicare and Medicaid Services (CMS) awarded $15 million in planning grants to 20 states and their Medicaid agencies to expand their crisis services, including mobile crisis teams.

A nationwide intervention is also near implementation. This will be a new 3-digit mental health crisis number, 988, and it will become operational by July 2022.

 The 988 number should allow mental health emergency calls to initially bypass police response. Thanks in part to advocacy efforts by the American Psychiatric Association (APA), the US House of Representatives passed several appropriation bills to increase funding for these and other mental health initiatives, some at unprecedented levels. However, as the reconciliation process continues, this funding is still in jeopardy.

As passed by the House, these bills would invest, for the first time ever, in creating a $100 million pilot program to support mental health mobile crisis response in lieu of police. It would also double the Federal Mental Health Block Grant for crisis services and expand funding for the Suicide Lifeline by $87 million to assist with the 988 transition.

 While these are small amounts compared to the billions of dollars being debated in increased spending for mental health and substance use disorder treatment and research, this funding, if fought to fruition, would indicate that the need for non-police response to mental health crises is being realized and pursued.

For my uncle and my patients, it will take years to create a sense of safety when calling for help. Whether or not we decide to fully invest in these programs will determine if our family members, friends, and patients with mental illness will continue to be criminalized and killed, or if they will have a chance towards recovery. Here lies the great opportunity for all of us: to demand support for these programs and to be aggressive advocates at every step in the process. Our voices matter and are making a difference.

is a resident in the Department of Psychiatry & Behavioral Services at SUNY Downstate Health Sciences University. 

 is director of public psychiatry education at SUNY Downstate Health Sciences University and medical officer at the US Department of Health and Human Services.

Effectiveness of police crisis intervention training programs

Decoupling crisis response from policing—a step toward equitable psychiatric emergency services

Risk of being killed by police use of force in the United States by age, race-ethnicity, and sex

Biden-Harris Administration awards $15 million to 20 states for mobile crisis intervention

. News Release. Centers for Medicare & Medicaid Services. September 20, 2021. Accessed November 15, 2021.

SAMHSA awards vibrant emotional health the grant to administer 988 dialing code for the National Suicide Prevention Lifeline

. Substance Abuse and Mental Health Services Administration. News Release. June 16, 2021. Accessed October 15, 2021.

APA statement on House passage of FY22 appropriations bill providing needed increases for mental health and substance use disorder programs

. American Psychiatric Association. News Release. July 29, 2021. Accessed October 15, 2021.

Can we save lives by dispatching mental health professionals as first responders to behavioral health calls?

Investing in Recovery: The Case for Supporting Non-Police Crisis Response

From preparing for the holiday season to clinical updates and psychiatric perspectives on social issues and contemporary events, 

 covered important topics this week. Top articles included:

Holidays are joyous for some, but not for everyone. How can you help patients with mood disorders navigate the difficulties of the holidays?

Shedding Light on the Shadow Brain Pandemic: The Devastating Effects of Gendered Violence-Related Acquired Brain Injury

In honor of the International Day for the Elimination of Violence against Women, let’s consider the impact of IPV on the neuropsychiatric health of women.

A Humanity Lesson From the Mouths of Babes

A child’s perspective, innocent and honest, serves as a good reminder of our biases.

It’s been a full week of interesting stories, commentaries, and more on a variety of topics at psychiatrictimes.com.