Hi, I Am Dr. Jonathan Sherin, Director of LA County Mental Health, AMA!

Dr. Sherin,

1. How can LA County better address substance use problems, especially among our homeless? I've had to acquiesce to vague primary diagnoses like "Mood NOS" even when I knew a patient's biggest immediate impediment was their massive meth or alcohol use. We had several ED high utilizers--people who smoked meth, become paranoid/agitated in the community, and routinely get brought into the hospital by the police. At times, when I tried to focus treatment on problematic substance use in the chart, I've been told by administrators that the substance use was "not a mental illness". 

2. What is going to be done about emergency room overcrowding? On rare busy mornings, I've literally had to walk over patients sleeping on the ground. At some point, so many patients in a locked environment has to be a safety hazard. Also, are there any new approaches to managing people who come in expressing suicidality for secondary gain?

3. Residency location plays a role in a physician's decision on where to practice. Is anything being done to make up for the lost Cedars Sinai and MLK training slots? 

4. What are the major barriers to better integrating medical and mental health care? Especially with regards to the electronic medical record and colocating medical/mental healthcare? The level of coordination between LA County's medical and mental health services is a large contrast to my experiences at Kaiser and the VA. 

There is debate about the differences between “pure” mental illness and “pure” substance addiction…in either case individuals are suffering tremendously and these two different diagnoses tend to co-occur in many cases. Through efforts to integrate care both within the department and between departments we aim to provide integrated services to individuals with integrated problems.

Dr. Sherin, How specifically will you be working to help people actually find their way to services? Your budget is enormous, but it seems that every one in LA County has a hand in the MH delivery system and there's no way for people (or their loved ones) to find what they need in a timely and consistent way. In other words, lots of $ seems to be wasted on lots of bureaucracy but so few actually the help they need. How will you work to fix this? And welcome to your new gig!

Access issues are primary concerns both at the Dept. MH and across health and human services. We aim to address these concerns through efforts to minimize stigma, increase knowledge about available services, streamline processes of navigation and improve customer service at the personal level. One of the key means for succeeding in these efforts is to expand the role of peers in our department to engage and provide “concierge-like” assistance to those having trouble accessing care.

A follow-up on peers. Paid positions? If so, how will that funding impact other programs? And what about training and other efforts to make certain standards are adhered to? I'm a great advocate of peers supporting recovery, but have seen it go wrong in far too many places and in oh so many ways.

For starters, all peers engaging in the serious business of caring for others need to be properly trained and receive certification as indicated given their role. It is my hope to expand opportunities for peers to become a core discipline in the Department not only through existing funding as well as expanding our resource streams. In particular this Department is committed to pushing for new legislation that will provide reimbursement through peer services at the state level.

Dr. Sherin, what percentage % of people are on Skid Row in LA because people they know in their lives have no idea how to get them help and what percentage % of people on slid row want no mental help themselves and people in their lives gave up on them or are these homeless are ignoring their family and friends despite the attempt's by their loved ones?

There is a significant number of people on Skid Row who are homeless and have serious mental illness and/or substance abuse issues. While a significant number of them are unwilling to accept help, surely there is a number of them who don’t know how to get help. It is our intention to engage both groups to get them the help they need.

How -- specifically -- will you be working on addressing the tremendous amount of inequality in the MH service delivery system across LAC?

We are currently in the midst of conducting GAP analyses across all 8 Service Areas in LA County. Although our initial focus aims to identify underserved cultural communities, we are also looking to determine other aspects of being underserved. For example: are we best allocating resources across age groups? For women? For veterans? For those suffering from psychological trauma? For homeless? For the justice-involved?

These are very complex questions to answer as they require not only determination of who is getting what where, but also depend upon whether our services are being offered in a welcoming fashion.

Dr. Sherin, thank you for doing this AMA!

With regards to society's perception of mental health, how can we reduce the stigma attached with mental illness and make the general public more accepting of people suffering from a mental illness?

On a personal level, is there any correlation between amount of sleep and number/severity of thoughts and compulsions for some with OCD? I have OCD and try to sleep as much as I can every night; I know that when I haven't had a good sleep schedule for a week or more my functioning drastically falls.

The need for sleep, like other neurovegetative functions, is core to health whether it is physical or mental. One easy way to think about it is to recognize that immune function and recovery from inflammation depend upon adequate amounts of sleep. Over time, with more and more biological research, I would predict we will find a strong correlation between sleep, inflammation, and mental illness.

Thanks for this AMA! I recently accepted my mental illness (bipolar 1) and I've realized how lucky I am to have insurance and the money to pay for my medicine.

My question is: how do you see the availability of treatment for mental health going forward in 10-20 years? I believe it's a massively under reported and under treated aspect of our society.

Through access initiatives, chief among them dismantling of stigma, it is my hope that both reporting and treatment of mental illness will rise to levels that rival those for physical illness. That said, I believe that certain technologies will provide new opportunities and solutions. One advance thatr we are working on currently leverages “FitBit-like” monitoring of mental health and well-being in combination with anonymous, virtual treatment paradigms to allow anyone to get help assessing their emotional state and receiving care in real time.

Another approach that we are interested in exploring involves the use of neuromodulatory interventions such as transcranial magnetic stimulation to augment other therapies.

Dr Sherin what are your thoughts on how to confront stigma and change someone's perception?

As someone who is bipolar, medicated and in counseling, I usually just don't tell people unless i have to, because there's just no awkward way to do it but sometimes people flip out like I'm going to set their house on fire on a whim with 0 provocation and i personally never know how to respond to that negative of a response.

“Mental Illness,” in my opinion, will someday be understood, viewed, and accepted as a challenge of the human condition just like any “physical illness.” To that end I see our fundamental responsibility as one in which we look to optimize mental health. It is only by optimizing mental health (as we do openly our physical health) that we will fully flourish as individuals, families, and communities.

Dr. Sherin, Thank you for doing this AMA. As a starting MFT trainee, I am curious about how the field is changing for therapists. I understand that in vivo services are becoming more common. How have you seen the field change and what should we starting out in the field expect in the next few years working within the mental health field in Los Angeles?

Over the last five years the Department has implemented a number of evidence based practices serving clients with symptoms of depression, trauma, substance use, and disruptive behaviors with demonstrated outcomes. We fully intend to increase the training of our staff and our partners to increase our capacity and provide more in vivo approaches to care.

Dr. Sherin, how do you de-stress during and after work from being around stressful people so much and so often?

I surf in the morning, I surf in the evening, and sometimes I just run or bike on the beach. These are my forms of meditation.

Dr. Sherin, what are your hobbies outside of work besides surfing? Do you play and watch any sports? Do you have any pets?

In addition to surfing, other sports that I enjoy include mountain biking (particularly downhill) as well as skiing. In fact, I used to ski race through college. Just recently I lost my incredible Bernese Mountain Dog named “Berner” after 14 years of exquisite companionship.