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May 3, 2019 by Bob Nikkel, MSW

Ten Lessons for Mental Health System Change

For the past several years, my blogs have centered on a topic that is admittedly not the most exciting – how policy can affect practice, especially in public mental health systems.  Distilling my 50 years of experience with a combination of direct work with people, management positions within local and state organizations and nearly 6 years as a state mental health and addictions commissioner, I think I learned a number of lessons about system changes.  But I haven’t taken a deeper dive into strategies, especially focused for advocates who seek significant and even radical changes – until now.
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March 14, 2019 by Bob Nikkel, MSW

Two Upcoming Webinars in Our Informed Consent Series

We have two outstanding webinars of great clinical relevance and interest coming up on the Mad in America Continuing Education Project.

Registrations are open at: education.madinamerica.com/p/what-would-real-informed-consent-on-drugs-look-like

On March 19, Dr. Sandy Steingard will talk about what informed consent can and should look like in a real life community mental health program. Dr. Steingard has been a leader in this country and is getting increasing attention elsewhere for her courageous and research-based approach to psychiatry. She is particularly well-prepared to discuss issues related to the use of psychiatric medications. You can see notice of her webinar here along with the learning objectives she will be addressing.

We are asking for a registration fee of $75 but it covers all 6 of the webinars in this series. You can contact me if you want to discuss an organizational rate or discuss a scholarship option.

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February 8, 2019 by Alita Kathryn Taylor, MA, LMFT

Love Is In the Air…

I am in love.  I’m in love with this way of working.  And I won’t stop.  Open Dialogue Washington began in 2018 upon my graduation/commencement from Jaakko Seikkula’s dialogic approaches to couple and family therapy trainer/supervisor training, in collaboration with Dialogic Partners and the University of Jyväskylä.

In 2016, I embarked to partake in the best training course I had ever experienced as a family therapist.  The embodiment I experienced working with my Open Dialogue colleagues felt like the missing key in psychiatry and psychotherapy.  Something intangible, yet what I knew all along.  Something ineffable, yet also a shared language.  Something deeply and autonomically human, yet unrepeatable and fleeting.   It led me onto a moment-by-moment path where everything I learned in my 27-year long career about systemic family therapy and emergency psychiatric protocols ebbed, and the present moment of love flowed, neither the ebbing knowledge nor the cresting wisdom having any lesser value than the other.  The complete work we do in mental health care is this ocean of love.

We are in constant change when we are in crisis.   Timelessness sets in.  Growth is happening.  We don’t exactly know what we need.  That is what mental health work is, sitting with this human happening.  In the in-between space something happens, and we don’t know what will.  This is the paradox.  We are navigating the ebb and flow of incoming knowledge we have from research and the ebb and flow in each patient and family’s difficulties (the meanings they make of them.)

“It cannot be taught, but it needs a teacher.”

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February 1, 2019 by RxISK.org

Serotonin Syndrome

(RxISK.org) – It is commonly recognized that certain medications should not be administered with some others. What is not well known is that several over the counter (OTC) medications and herbal supplements can be lethal if taken with SSRIs.

I have a patient who was taking fluoxetine and, experiencing some difficulty with sleep, decided to take one tab of melatonin.  He woke up with a red and burning face, headache and blood pressure of 230/180.  He was in a full serotonin syndrome.

Serotonin syndrome symptoms often begin within hours of taking a new medication that affects serotonin levels or excessively increasing the dose of one you are already taking. Symptoms may include: Confusion, agitation or restlessness, dilated pupils, headache, changes in blood pressure and/or temperature, nausea and/or vomiting, diarrhea, rapid heart rate, tremor, loss of muscle coordination or twitching muscles, shivering and goose bumps, heavy sweating.

This syndrome may develop within hours to days of increasing a serotonergic dose or adding a serotonergic agent to a drug regimen already containing a serotonergic medication. Symptoms range from mild and chronic, to others that progress quickly to death.  My patient is lucky to be alive.

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January 21, 2019 by Craig Wagner

The Good, the Bad, and the Ugly: An Infographic on Bipolar Drugs

This post helps make sense of the mountain of bipolar drug research. It distills into an infographic the pros and cons of five classes of bipolar drugs and gives observations on what it means for people who face choices on bipolar care.

Although this post wanders deeply into the statistical weeds, we avoid technical jargon. To maintain statistical rigor, we use technical definitions for important phrases below. [1]

(The infographic is kept fresh as research evolves. The latest version with footnotes is always here.)

A few key perspectives behind this infographic deserve attention:

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January 14, 2019 by Sandra Steingard, MD

Open Dialogue: Does the Current Research Data Support Further Investment?

Psychiatric Services, a leading US journal, has published two important papers on Open Dialogue. Freeman and colleagues did an extensive literature review and analysis of currently available research. Their paper is accompanied by a commentary by Kim Mueser, PhD, Director of the Boston University Center for Psychiatric Rehabilitation and one of the world’s experts in his field.

Freeman and colleagues begin their paper with a detailed explanation of the criteria for inclusion into their investigation. They identified 23 studies for review. Papers selected were published in English and evaluated Open Dialogue effectiveness using either case study, qualitative, quantitative, or mixed methods. Studies were conducted in Finland, Norway, Sweden, and the US.

As the authors point out, most of the available research comes from the Western Lapland group that developed Open Dialogue (OD). This poses a fundamental source of weakness in the evidence base. Their studies had small sample sizes, there was no control group, and the ratings were not blinded. In addition, there were not consistent methods for either defining or evaluating OD.

Many of us learned of Open Dialogue because of their reported excellent outcomes for individuals who experienced a first episode of psychosis. We are eager to see if these results can be replicated elsewhere. But there are other important questions.

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November 20, 2018 by Bob Nikkel, MSW

What Would Real Informed Consent on Psychiatric Drugs Look Like? New Webinar Series Begins January 22

I’m excited to announce a new series of Mad in America Continuing Education webinars for 2019. They focus on what I believe is a central issue—what does a true informed consent process look like for the prescription of psychiatric drugs? This is a leverage point for changing the paradigm of care by starting with how people are informed about what psychiatric drugs do.

I believe that righting this ship is largely going to be up to non-medical mental health professionals and persons with experience in having been through a system that fails miserably to provide real informed consent. Since we are a continuing education program, our courses are designed primarily for the first group: psychologists, social workers, nurses, licensed professional counselors, and marriage/family therapists. We will continue to apply for continuing education credits (CEs) and at some point recruit more interest from physicians so it would be worthwhile to apply for the more expensive continuing medical education credits (CMEs).

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October 28, 2018 by Sandra Steingard, MD | Community Mental Health Journal

Five Year Outcomes of Tapering Antipsychotic Drug Doses in a Community Mental Health Center

Abstract

There is evidence that many individuals are on higher doses of antipsychotic drug than is required for optimal functioning yet there are limited guidelines on how to reduce them. This paper reports on 5 year outcomes for sixty-seven individuals who received treatment at a community mental health center and were offered the opportunity to gradually reduce their doses of antipsychotic drug in collaboration with the treating psychiatrist. Over a period of 6 months, the author invited patients who were clinically stable and able to participate in discussions of potential risks and benefits to begin gradual dose reductions. Initially, 40 expressed interest in tapering and 27 declined. The groups did not differ in age, sex, race, or diagnosis. The group who chose to taper began on significantly lower doses. Most patients succeeded at making modest dose reductions. At 5 years, there were no significant differences in the two outcomes measures, rate of hospitalization and employment status. Many patients were able to engage in these discussions which did not result in widespread discontinuation of drug. This is a naturalistic, small study of a topic that warrants further research.

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September 7, 2018 by Joseph Firth et al | World Psychiatry

Diet as a hot topic in psychiatry: a population‐scale study of nutritional intake and inflammatory potential in severe mental illness

Joseph Firth Brendon Stubbs Scott B. Teasdale Philip B. Ward Nicola Veronese Nitin Shivappa James R. Hebert Michael Berk Alison R. Yung Jerome Sarris

(World Psychiatry) – People with severe mental illnesses (SMIs) – including schizophrenia, major depressive disorder (MDD) and bipolar disorder – have excessive caloric intake, a low‐quality diet, and poor nutritional status compared to the general population12. Poor diet increases the risk of diabetes and cardiovascular mortality in this population3. Furthermore, excessive consumption of high‐fat and high‐sugar foods can increase systemic inflammation4. Indeed, all classes of SMI show heightened levels of peripheral inflammatory markers, which is linked to worse prognosis in these conditions. However, there currently is an absence of large‐scale studies comparing the nutritional intake and inflammatory profile of the diets of individuals with SMIs.

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August 29, 2018 by Kermit Cole

When Rain Comes, Words Are Unnecessary: Our Search for a Better Way

Living in New Mexico means hoping for rain. The state is in drought, with most areas officially in either “extreme” or “exceptional” drought. The soil is full of life waiting for a chance to express itself, but the rare rain forecasts usually promise only “scattered showers nearby,” with the outcome being either clear blue skies or the sight of rain falling elsewhere. New Mexico is also one of the poorest states in the U.S., with more than one in five New Mexicans, and one in four children, living in poverty. We are second in the nation for the prevalence of youth living without connection to work, school, or family. New Mexico ranks high (#7) for people living with serious mental and emotional challenges.

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