Southlands: December 2022

SOUTHLANDS

The Newsletter of the Southern Psychiatric Association Volume 8, Number 2 DECEMBER 2022 Article Title

Author

The President’s Column

Thomas Franklin, MD

2

Executive Director Update

Janet Bryan

2

Report From the APA Assembly

Mark Wright, MD

3

Program Committee Update

Mark Wright, MD, Phil Scurria, MD, Janet Bryan

3

Report From the Annual Meeting

Bruce Hershfield, MD

3-5

The Heart of a Therapist

Mary Helen Davis, MD

6

Survivor Guilt & the Upcoming Holidays

Jenny Boyer, MD

6-7

Interview: Thomas Franklin, MD

Bruce Hershfield, MD

7-8

Psychiatry: What Happened, What’s Next

Shree S. Vinekar, MD

8-10

What Happened to Psychiatry: The Last 30 Years

Thomas Franklin, MD

10-11

Dehydration: Therapeutic at the End-of-Life

Steven Lippmann, MD

11-12

Butler Hospital, Abraham Flexner, & Johns Hopkins

Steven Lippmann, MD

12

New Hope for Combating Postpartum Depression

Audrey Summers, MD & Steven Lippmann, MD

12-13

Adolescent Suicide During the Pandemic

Sendhiul Raj Karmegam & Steven Lippmann, MD

13-14

Mental Health & Gun Violence – What Are The Facts?

Srija Chowdary Vanka & Steven Lippmann, MD

14

Suicidal Impact of Firearms During COVID-19

Nishi Chandrasekaran & Steven Lippmann, MD

15

Nitrous Oxide Abuse: Just Laughs or Something More Sinister?

Clayton Olash, Syed A. Abbas, MD & Steven Lippmann, MD

16-17

COVID-19 Induced Psychosis?

Neil Kidambi, MD, Omar Elsayed, MD & Steven Lippmann, MD Muruga Loganathan, MD Marina Nikhinson, MD Jonathan Scarff, MD Andrew Tuck, MD Eveleigh Wagner, MD James C. West, MD

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Welcome New Members

Page

17-18

In Memoriam: Brian Crowley, MD

Bruce Hershfield MD

18

Letter From The Editor

Bruce Hershfield, MD

18-19

Save the Date:

October 11 – 15, 2023 in Huntsville, Alabama

2023 Annual Meeting Dates

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The President’s Column By: Thomas Franklin, MD

Executive Director Update By: Janet Bryan In September, we had our first inperson Annual Meeting in two years. If you were unable to attend, you missed an incredible joint meeting with the Maryland Psychiatric Society. The attendance and exhibitor support was better than pre-pandemic meetings, the receptions were enjoyed by all – especially the amazing event at the Rusty Scupper Restaurant overlooking the picturesque Inner Harbor.

We were honored to have several Area 5 Council members attend the Farewell Gala Dinner on Saturday evening where everyone enjoyed the music of local jazz band Sac Au Lait. I am excited to report that with the attendance and exhibitors, we had a profitable meeting.

First, I’d like to thank everyone who has been so kind helping me get up to speed, particularly Many Helen Davis, Bruce Hershfield and Janet Bryan. While the Southern is a smaller organization, its warmth and friendliness allow us to “punch above our weight” in every area, since people who actually know and care about one another work together so much more effectively.

What it means to be a physician has been evolving rapidly for a generation, and the COVID-19 pandemic accelerated many of these changes. In years past, it was expected that doctors would go to meetings to get their CME, but those days are over with the advent of online instruction. Organizations of all sizes are in a transitional period where in-person attendance is going down as younger doctors see themselves more as employees of larger organizations, rather than professionals with obligations to the guild and the next generation of doctors. Some psychiatrists don’t even see their patients in person anymore – let alone their colleagues.

At the Business Meeting, the officers were approved.

Below is the list of officers for 2022 – 2023: President, Thomas Franklin, MD President Elect – Mary Jo Fitz-Gerald, MD Vice President – Rodney Poling, MD Secretary-Treasurer – Raymond Kotwicki, MD Board of Regents: Chair: Lauren Pengrin, DO 2nd Year: Felix Torres, MD 1st Year: Chasity Torrence, MD Immediate Past President – David Casey, MD

While these changes may be lamentable, they are an opportunity for an organization like the Southern. For a long time, our membership numbers have been stagnant and the average age has been creeping up. This is reflective of the aging of the psychiatric workforce more generally. If we don’t recruit new members and position ourselves intentionally in the changing organizational landscape, we could cease to exist in another decade.

Each year, the annual membership dues are payable in January. This year, you should have received a notice in the mail and an email from me regarding your dues payment. If your contact information (address, phone, or email) has changed over the last year or if you have any questions regarding your dues, please email me at jbryan@sheppardpratt.org.

What we have is a collegial group that offers not only a vibrant educational program, but also vaunted Southern hospitality. Most large meetings are an impersonal circus with a huge marketing presence that is off-putting to many. With people able to get all the CME they need in their pajamas from home, and professional isolation increasing markedly, there is a market for smaller groups that offer meetings that are more manageable with various networking opportunities and social events.

This year, we have had eight psychiatrists join: Dr. Valerie Arnold, Dr. Dan Dahl, Dr. Muruga Loganathan, Dr. Marina Nikhinson, Dr. Jonathan Scarff, Dr. Andrew Tuck, and Dr. Curt West. Dr. Tuck was this year’s Resident Research Award Winner.

I ask you to encourage your colleagues to become members of the Southern Psychiatric Association. Please connect me with anyone who is interested so that I can provide the application.

I believe it is time to invest in a revamping of our website and marketing of ourselves, focusing on Southern hospitality, which is an idea that already resonates with people generally. I think this concept is very “of the moment” and needed more than ever. We just have to get the word out to more people about it. We are a smaller psychiatric organization with quality speakers that actually makes it worth your while to come in person – with numbers of built-in social events, great meeting venues, and friendly people.

The Program Committee is diligently working on the agenda and speakers for next year’s meeting. Please mark your calendars for our 2023 meeting scheduled with Alabama Psychiatric Physicians Association from October 11 – 15, 2023, at the Westin Hotel in Huntsville.

Wishing everyone a wonderful holiday season and happy new year.

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Report from the APA Assembly By: Mark Wright, MD

Program Committee Update

The Assembly of the APA met virtually on November 5th and 6th.

By: Mark Wright, MD, Program Chair for 2022 Meeting, Phil Scurria, MD, Co-Chair, and Janet Bryan

It passed an action paper that asks the APA not to plan national in-person meetings or conferences in states without full access to reproductive health care, including abortions. It should be noted that Area 5, which represents the southern states, was strongly opposed to this. If approved by the Board of Trustees, this could have a significant impact on meetings of Area 5.

Thank you to the Program Committee who planned the 2022 in-person meeting this past September and the 2021 virtual meeting. At this year’s meeting, we were very fortunate to have 18 amazing speakers, thoughtprovoking topics, 77 registrants, and wonderful exhibitor support. Dr. Bruce Hershfield’s article (see below) provides highlights from each of the scientific sessions from the September meeting.

It also approved an action paper requesting the APA to formulate and release a recommendation that the age to purchase firearms and ammunition be raised to 21. It also voted to reaffirm addressing firearm safety as an organizational priority.

It approved an action paper requesting the APA to develop a position statement on assisted suicide and inability to determine mental illness irremediability.

A huge thank you to our exhibitors – without their support, we would not have a profitable meeting. This year’s exhibitors were Gold Sponsor Professional Risk Management Services, Silver Sponsor American Professional Agency, Alpha-Stim who sponsored the lunch, Alkermes, Inc., Bioxcel Therapeutics, Caron Treatment Centers, Centurion, CooperRiis Healing Community, Corium, GeneSight, HopeWay, Intra-Cellular Therapies, Inc., IDgenetix, Janssen Pharmaceutical, Maryland Addiction Consultation Services, Maryland Addiction Consultation Services for MOMs, Maryland Addiction Recovery Center, Maryland Department of Health, MindWork Group, Otsuka America Pharmaceutical, Sage Therapeutics, Sheppard Pratt, Sunovion, and US Army Healthcare.

It asked that the text of the outgoing and incoming Presidents’ speeches be published in the APA Journal in the issue closest to the change in officers.

We are actively planning the meeting for October 11 – 15, 2023 in Huntsville and are looking forward to another wonderful in-person meeting.

It requested that the Board of Trustees re-instate two Assembly in-person meetings a year rather than the inperson meeting at the Annual Meeting in May and a virtual meeting in November.

Report from the Annual Meeting MPS & SPA: Baltimore: 9/7/22-9/10/22 By: Bruce Hershfield, MD

It voted unanimously, through the consent calendar, to ask the APA to advocate on behalf of its members for the American Board of Psychiatry and Neurology (APBN) to decrease rates so that they are commensurate with the product being delivered. It also asks for financial transparency from the ABPN regarding its proceeds related to Maintenance of Certification.

It also voted to accept the slate of officers presented by the Nominating Committee. I represented SPA on the Nominating Committee as the ACROSS representative.

Here are some notes from the scientific sessions held at the Royal Sonesta Hotel: The meeting began with a Firearms & Psychiatry Panel.

Steve Lippmann started by discussing Guns & Violence.

He cited some upsetting statistics: more Americans are killed by guns than by motor vehicle accidents, and guns are the # 1 cause of death in children. The USA had a ban on assault weapons from ’94-’04. Buy-back programs in Australia and NZ were successful. Background checks, minimum age requirements, and registering serial numbers are all popular ideas. Congress passed a Safe Communities Act in June. He pointed out that the per capita death rate from guns is actually higher in rural areas than in urban ones. There has been recent discussion of who can be held legally liable for firearm deaths beside the people who actually fire the weapons.

He ended by asking what we can do to lower the rate of firearms deaths.

Two Area 5 individuals are running for Assembly Office: Steven M. Starks, MD for Speaker-Elect Deborah Barnett, MD for Recorder If you have any questions, please notify me at SPAAssemblyrep@gmail.com

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He was followed by Paul Nestadt of Johns Hopkins, who spoke about “Suicide & Lethal Means”. Suicide is the 2 nd leading cause of death among those under 40 years old.

He went on to discuss risk factors: for example, living alone doubles or triples the risk. Of the 47,000 suicides, 53% result from gunshots. Firearms cause death in 89.6% of attempts, while cutting only causes 0.7% to die. It turns out that 71% of attempts occur within one hour of deciding to do it. Since the choice of method depends on availability of means, allowing more access to guns increases the risk. The rate is 4 times higher in soldiers who take their weapons home with them. Making gun laws more stringent decreases the suicide rate by 20%.

Lock boxes and gun safes are options for decreasing the rate, as are plans for safely storing weapons when there is a crisis.

Vagus nerve stimulation provides a small electric current for 30 secs every 5 minutes, on a 24/7 basis, but it is difficult to get insurance companies to pay for it.

To close the day’s scientific sessions, Andrew Tuck of Duke Univeristy spoke about Execute Death Row Offenders with & without a History of Psychosis. This was the Resident Research Award-winning paper. He reviewed the history of this punishment, noting the moratorium that existed between 1972 & ’76 and telling us that Texas has recently executed more than any other state. People who are psychotic are more at risk for violence, particularly homicide, and are less likely to be intoxicated than non-psychotic offenders. Of the 332 executed in Texas, 2000-15, 7.5% had a history of psychosis. They were more than twice as likely to admit guilt when arrested, more likely to eventually acknowledge guilt, and less likely to express love in their final messages.

Curt West then told us about Talking to Patients about Firearms & Safety. There are 10 million more guns in the U.S. each year and more than 40% of households have them. To increase safety, he suggests storing guns unloaded, disabled, locked, and separate from the ammunition. He then discussed the barriers that prevent people from talking about safe storage. He said that 78% of people believe it’s OK to talk with their doctors about firearms and 64% report that when they received counseling it changed their practices.

Day 2 Scott Aaronson began by telling us about The Emerging Evidence for the Use of Psychedelic Psychotherapy in Mood Disorders. He said that after 60 years of being bound by the monoamine theory, we are entering the age of interventional psychiatry – doing things to patients. He gave a brief history of our knowledge of psychedelics.

Psylocybin enhances the brain’s capacity for plasticity, which is diminished in most psychiatric disorders. The “default mode network” is active when the brain is at “wakeful rest” – and in most depressed people.

Psychedelics stimulate synapse formation.

The next speaker, Carol Vidal, talked about Trauma – Informed Care: When Work Safety is at Stake & the Trauma is in the Workplace. During trauma, the amygdala is activated and frontal lobes shut down. The concept of what is traumatic has spread; not everything that happens is really traumatic and some things that appear to be traumatizing do not have that effect on everyone. Traumainformed care involves treating the whole person, not just the symptoms. She went on to talk about burnout’s characteristics: emotional exhaustion, depersonalization & a diminished sense of professional efficacy. It may be present in as many as 54% of physicians in the USA. She noted that MD’s and RN’s suffer high rates of experiencing aggression, and she listed 10 ways of combatting aggression and preventing burnout.

The first psychedelic that is likely to be approved is MDMA, for PTSD, next year. In a study at Johns Hopkins, 71% of major depressive patients showed response to psilocybin and in another study 75% showed response and 58% went into remission. Patients with bipolar II depression also can respond dramatically to it.

Psychotherapy is an important part of the success – the treatment in his office is delivered in a 9-hour session with 2 experienced psychotherapists available. It is too expensive to be a 1st-line treatment now.

Monica Rettenmier then spoke about Neuromodulation & Treatment Refractory Illness, pointing out that ECT is still the most effective and reliable treatment for severe depression. Delivering the current in brief pulses leads to fewer side effects than delivering it in sine waves. ECT leads to 80%-90% remission in depression – even to 50%-60% in the severely resistant ones. There are no absolute contraindications. Side effects can include headache, muscle aches, and anterograde and retrograde amnesia. It is still not clear how it works. She went on to describe TMS, which has been approved for MDD (without psychotic features), OCD, smoking, and migraine. It is provided 5 days per week for about 6 weeks. Side effects can include scalp sensitivity and headaches, but they tend to go away within one week.

The response rate in MDD is 50%-60%, with 33% remission.

Glenn Treisman, who had been called away for a family emergency, then delivered a videotaped talk about Chronic Pain & the Opiate Epidemic. He pointed out that opiates are effective for acute, but not chronic, pain, and their use can lead to rebound. Doctors have been pressured to prescribe opiates, but there have been a huge number of opiate-related deaths. Patient satisfaction with their opiates is unfortunately correlated with increased mortality. There has been a decrease in prescriptions since 2012, but the death rate increased because patients then switched to illegal opioids like fentanyl. Depression worsens the other contributory factors and makes prescribing more difficult. He pointed out that extroverts are more vulnerable to developing opiate abuse.

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Mary Helen Davis then lectured about The Long Arm of COVID. There have been over 1 million deaths from it in the USA and 6 million in the world. From 20%-25% have had sequelae. There have been increases in alcohol and opiate-related deaths and in the incidence of mood and anxiety disorders. Half of patients who were hospitalized for COVID have at least one symptom two years later. Of patients who have the disorder, 33%-62% have a neurological sequel after 6 months. Most of the longCOVID patients eventually recover. The condition is more common in females and increases in patients over 70.

and tegretol. Brexanolone, a synthetic neurosteroid, affects GABA receptors and is delivered in a 60-hour IV drip.

Day 3 David Casey began the Saturday talks with one about Vincent Van Gogh. He had a family history of psychiatric problems, was odd as a child, and was an academic under-achiever. He had his first breakdown after a failed love affair, became ascetic and served as a lay missionary, then studied art (though he failed to finish).

He had his second breakdown and moved to Antwerp and then Paris, and then to Arles at 35. He felt that Gauguin had rejected him, and he cut off his ear. He had repeat hospitalizations, moved closer to Paris, then shot himself.

He is now regarded as one of the most important figures in western art. Diagnostic possibilities include porphyria, bipolar disorder, and temporal lobe epilepsy. It is ironic that the most important part of his life occurred in the last two years, when he was most ill.

Dale Bratzler then spoke more about Long-term Consequences. Life expectancy has been decreasing, particularly for minorities. He spoke about long COVID’s psychiatric features, noting that anxiety and depression, though common, tend to be transient. The virus tends to stay in the body a long time and one can see patterns of immune system dysregulation. He pointed out that the delta variant was more likely to protect patients from getting it again, compared to the alpha type.

After lunch the sessions shifted to a Geriatric Psychiatry Panel. Karen Neufeld began by talking about delirium in the acute hospital. Delirium is a disturbance in attention/awareness with new cognitive deficits, due to underlying physiological factors. It is easy to miss delirium on screening, particularly in hypoactive patients. Beware of the “sleepy” patient, who may quickly become comatose. Find the underlying cause and correct it (or them). No medication specifically prevents or treats it.

Mobility helps decrease the duration; haloperidol can calm the patient down, but it does not decrease how long the condition lasts.

Todd Peters & Deepak Prabhakar next comprised a panel on Children & Adolescents, discussing the Impact of Pandemic on Child Development. In 2009-19 there was an increase in youth suicide and a dramatic increase in those planning to do it. The increase in social media/tech bullying, and school shootings, may account for much of that. Once the pandemic struck, depression and anxiety symptoms doubled. Visits to ER’s for suicide attempts in adolescents increased about 41%-51%. Being in an urban area, having a parent who was a frontline worker, disruptions in routine, and losing someone to COVID were factors. One child in 4 lost a parent or a grandparent/ caregiver.

Louis Marino then told us about Psychosis in the Elderly.

About ¼ of people who develop psychosis do it after they turn 40. Those who have purely delusional disorder are otherwise not noticeably impaired. They are highly resistant to the idea of taking medication. About 1/3-1/2 of Alzheimer’s patients show increased aggression, and those have a shorter lifespan. Pimavanseran can help with delusions. Up to 75% of those who have dementia with Loewy bodies can become psychotic, as do about 10% of those with frontal-temporal dementia.

Mary Jo Fitzgerald then spoke about how her hometown of Shreveport was a leader in treating addiction to opiates about 100 years ago. She pointed out that opiate abuse was more common in the south then, and she talked about the Pure Food & Drug Act and the Harrison Narcotics Act. There was a clinic in Shreveport after one in New Orleans closed, but that soon also closed because of harassment.

The sessions closed with a talk by Nitin Gogtay of the APA about DSM-5-TR. He talked about Prolonged Grief Disorder and the changes in schizophrenia spectrum disorder and autism spectrum disorder. He pointed out that “unspecified mood disorder” was restored.

“Dysthymia” was removed from “persistent depressive disorder. The USA is still using ICD10-CM instead of XI. He concluded with comments about suicidal behavior and non-suicidal self-injury.

Julia Riddle next talked about Treatment in Pregnancy.

She described the changes in sleep patterns that pregnant women have. She talked about post-partum depression, noting it can be present in up to 20%. She said all new mothers (and some new fathers) have “intrusive thoughts” and 85% have the “baby blues”.

Discontinuing medications during pregnancy can lead to a relapse rate for depression of 70%. She suggested developing a sleep plan during pregnancy, having a conversation about the risk of continuing vs. stopping medication, and trying to avoid suddenly stopping medication. The dose may have to be increased after delivery because of biological changes in the fluid volume.

About 20%-30% of newborns experience withdrawal if their mothers were taking SSRI’s. Avoid using Depakote

There was a lot of material and much of it was very relevant to clinical care. Many thanks not only to the speakers (and the audience members who contributed) and also to the Program Committees and those who so skillfully organized the meeting!

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The Heart of a Therapist: Some Principles I Have Found Helpful By: Mary Helen Davis, MD

4. Substitute Curiosity: Be open when considering someone’s behavior, setting aside any judgmental tendencies. Use your ability to accept and to empathize.

5. No Drama: Our patients tend to come from less–than-ideal--often chaotic – environments. If you don’t like drama, don’t go into the theater. Stay seated and don’t accept the invitation to get up on the stage. I have used this phrase a lot, especially at the holidays. I often pair it with “Don’t bite on bad bait.”

The title of this article is a tribute to Elvin Semrad, a psychoanalytic psychiatrist frequently quoted during my fellowship years in the Boston community. His quotations regarding patient care were later published in The Heart of a Therapist by Susan Rako.

6. The better you are, the better you get: Success promotes success. By building upon improvements, patients go from symptoms to remission.

Our professional world is undergoing significant transitions. Emerging “collaborative care models” place physicians as leaders of a multidisciplinary team that may include APRNs, physician assistants and other mid-level providers. Our relationships have grown both complex and controversial. Our expertise, and how we use it, matters. An early-career APRN told me once, “If I had a million dollars, I’d gladly exchange it for 10 years of your clinical experience”. I now realize this was an early indication that our collaborative agreement would be fruitful.

7. Never take one vacation without knowing when and where the next one is: It’s important to take time off.

Our patients can benefit from a mini-break or a “staycation”. Both they and we need to plan to take time off.

8. Foster Resilience: Identify the people who are supporting your efforts, be a part of a community, and work on developing meaningful connections.

Recognizing a willingness to learn and appreciating the differences in training and experience can help minimize the strain in some of these inter-professional relationships. It will require a lot from us to learn how we can best share our wisdom with so many people. Here are a few of the principles I have learned to use in both supervision and therapy:

The SPA membership collectively has a depth of clinical knowledge, experience, and wisdom. Most of us have been practicing for many decades. At our last meeting, the Executive Council discussed ways we can share our knowledge and expertise with our colleagues and with residents and medical students. Perhaps we can collect our members’ clinical “pearls” so we can all use the ones we like when we are teaching. The Southern has a lot of heart; this is a way we can best use that by acting together.

1. Change is inevitable, embrace the suck: I began my psychiatric training during the transition from DSM-II to DSM-III – when the field was shifting its emphasis from psychoanalysis to pharmacotherapy. I learned that ongoing change is a permanent part of organizational and institutional life. It’s particularly difficult to adapt when one is satisfied with the status quo. I was teaching trainees to complete their documentation at the end of each session, when the whole system changed because of electronic medical records. I learned to embrace the suck— a phrase I learned from a backwoods guide who was taking adolescents on treks.

Survivor Guilt and the Upcoming Holidays By: Jenny Boyer, MD APA Area V Trustee It is time for the typical peak in survivor guilt, particularly in marine and army combat veterans. During the holidays, when veterans get together with family, guilt over being alive emerges. It is hard for them to tolerate closeness with a group of extended family members whom they do not regularly see. Family members say “What is wrong?” and it becomes embarrassing for the vets to articulate the reasons why they are withdrawing or are angry. They often have never articulated their survivor guilt to their families. Their relatives do not understand.

2. Identify and consolidate strengths – both your own and the patients: During my child psych rotation, we were taught to ask each patient for 3 wishes. Now I ask my adult patients to identify 3 strengths. This helps me understand how they see themselves and gives me tools to help them recover. It also helps protect both of us from getting demoralized.

3. Beware of the “fuzzy strawberry”: A moldy strawberry will soon ruin the whole box. The ability to identify “moldy” behavior or personalities can lead to understanding a toxic environment and can guide boundary-setting.

I like to work at Thanksgiving and Christmas because it is a wonderful opportunity for me to support these veterans.

One subsection of survivor guilt is “moral injury”, which makes Thanksgiving and Christmas especially difficult.

Service members had to survive or be killed, but many feel at some level that they did immoral acts to save themselves.

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Family prayers are usually said in large groups before the traditional meal, and it is particularly difficult to hide sadness in those settings. In some families we recite prayers about those who have died and that can also be very difficult for veterans who were in combat, since mentioning any death can bring up the memory of those who died in one’s “military family”. I try to warn the veterans in my family before we speak about this. I also try just to listen.

Mindwork Group – a practice we hope will grow into something where people can come for treatment that is more intensive and psychotherapeutic. We will be opening an intensive outpatient program in October. Right now you have to go to a residential treatment center to get that, and we are hoping to be able to offer it on an outpatient basis.”

Q.: “Tell us about how you got interested in Psychiatry in the first place.”

I cannot really understand, as I am not a combat veteran, but I do want to understand. I am grateful for my freedom and for the opportunities we have to celebrate all that the veterans have done for us.

Dr. Jenny Boyer, who is an SPA member, is a candidate for APA Secretary. Her opponents are Drs. C. Freeman of California and Gabrielle Shapiro of New York.

Dr. F.: “I came to medical school interested in Psychiatry.

I tried to keep an open mind. I was all in on Psychiatry one night when I was on critical call at the University of Virginia, and we admitted 17 patients with heart attacks.

Every one of them had the same treatment plan!

Psychiatry offered infinite ways that people can present.

No two cases are all that much alike. Getting to know people intensively and to be with them on their journey was always very appealing to me.”

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Q.: “How did you come to the Baltimore area?”

Interview: Thomas Franklin, MD President-Elect, SPA Baltimore September 8, 2022 By: Bruce Hershfield, MD

Dr. f.: “After my residency at the University of South Carolina, I did a national search of what was available. I considered private practice and some academic jobs.

Sheppard offered an amalgam of both – a place that was somewhat academic, but was mainly about clinical care. I wanted to take care of patients, and at a high level.

Sheppard was surely a place where I could do that.”

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Q.: “What plans do you have for the Southern, starting for when you become President on October 1 st?”

Q: “What would you do differently if you could do it over again?”

Dr. F.: “Steve Sharfstein recruited me to the Southern several years ago. I’m from the south – I was born in Tennessee, and my father’s family is from Georgia.

Joining was a way for me to think about my own southern roots and to make a connection. I did relocate and made a life just south of the Mason-Dixon line. We have a really lovely organization that is small enough to have meetings where people really get to know one another and to have meaningful personal interactions. In these days of zoom meetings, that is far less common. But it is big enough for us to have a quality scientific program. We can build on our strengths.

Dr. F.: “I think I would have stayed in a training and supervision mode after Residency. It’s very common right after Residency to feel a little burned out about being a student. I took a long break from that – 5 or 10 years before I started my psychoanalytic training. If I had to do it again maybe I would have only taken a year or two to get settled in my job and would have gotten involved in furthering my education a little earlier.”

Q: “What have you enjoyed most about your work?”

We have to offer more to members than just CME and meetings if we are to be around for another 80 years.

Particularly, young people, including psychiatrists, have a very different sense of what it means to be a physician.

They have been acculturated to different ideas about their career identities. If the Southern is to be relevant to those folks, we need to meet them where they are, instead of expecting them meet us where we are.”

Dr. F.: “My relationships with patients and their families and my colleagues. That enlivens me. Doing intensive work with people over time is so deeply satisfying.”

Q: “What are your plans for the future?”

Dr. F.: “I hope to grow Mindwork Group into a center of excellence for outpatients who have complex or moredifficult-to-treat problems, including substance use disorders. I am very hopeful that once we get our intensive outpatient program up and running, we will be able to become a training site – not just for psychiatrists, but for all mental health practitioners who are interested in learning how to deliver this kind of care. That’s less common these days and you run into some clinicians who have never really been exposed to it.”

Q.: “Tell us what you do.”

Dr. F.: “I was at Sheppard Pratt for nearly 20 years and helped build the Retreat and Ruxton House and some of the other private-pay psychotherapy programs. We were also proud to help Sheppard do some of the other things it does around the state. But a couple of years ago I left there and went into private practice and founded

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“Sarpasil” was still used as an effective antihypertensive and antipsychotic. Reserpine depleted the dopamine in the limbic system; this could lead to severe depression.

The role of biogenic amines in mental illness was not very clear until the mid or late 1960’s.

Q: “How can we help you accomplish your goals?”

Dr. F.: “Get involved, either with the Southern or the Maryland Psychiatric Society or the APA. The future of our profession is very much in doubt right now, and if we don’t get behind the wheel as psychiatrists other people will drive the bus for us. That has surely happened in many ways in the last generation or so. In the next 10 or 20 years, what it means fundamentally to be a psychiatrist – If we aren’t thoughtful about it – will be unrecognizable to us. So get involved – with patients, for example.

Whatever you do with patients, set aside some time to work intensively with some. It’s deeply satisfying and doing it can enliven all the rest of what you do. Carve out two or three hours per week so you can see a few more intensively.

One of my senior colleagues had resigned from the state hospital because there were only 6 psychiatrists to care for 6000 patients, and there were nearly 6 suicides monthly there. A few years after completing my residency in a University Hospital, I worked in a State Hospital that housed 1500 patients. One-fifth of these were under my care, and I was only officially working 60% of a work week. This was much better than caring for 6000 patients with 6 psychiatrists. My job was to move them out into the community setting, including nursing homes. Many ended up homeless. There were thousands of psychologists and counselors who meant well in the community, but they were not of much use to the hundreds of thousands confined in the state hospitals.

I would like my time as president of the SPA to be generative. I would like us to have a panel discussion in Huntsville next year about the future of Psychiatry and how we night be able to affect it.“

The state hospital-employed psychiatrists, who were frustrated with a lack of effective treatments for the mentally ill, themselves wanted to be treated by psychoanalysts. Oklahoma had one psychoanalyst in the 1950s and 12 psychiatrists, mostly those who worked in the state hospital, started treatment with him.

Psychiatry: What Happened, What’s Next By: Shree S. Vinekar, MD

Many of these state - hospital - trained psychiatrists had very little experience in understanding neuroses, and they started diagnosing schizophrenia and bipolar disorder when they began treating community-based patients, possibly because they had no training in exploring psychodynamic factors. Of course, their strong medications helped their neurotic symptoms, like cannons working better than BB guns. The role of trauma, adverse childhood experiences, abuse and neglect, maternal and affectional deprivation, social and sensory isolation, social/racial discrimination, and inner conflicts, often went unrecognized and untreated. That is true for most patients even now.

In my experience in Psychiatry from 1964 until now, there has been a lack of progress in caring for the “mentally ill”.

When I started exploring residencies, most of the State Hospitals were in rural areas and many were understaffed, housing nearly 10,000 patients. Senior psychiatrists told me that the situation had been much worse in the 1940s, when there were no effective treatments for patients except for some of those who had syphilis-induced insanities. The rest of them were suffering from chronic schizophrenia and “manicdepressive psychoses,” dementias, and irreversible sequelae of traumatic brain injuries or alcoholism. These illnesses were all considered “chronic” or non-treatable, just to be “managed.” “Lock them up and throw away the keys” was the general societal attitude of extrusion of the mentally ill.

Not much was known about the etiology of psychosis at that time. One local analyst started talking about how he was like Jesus Christ, and he had 12 disciples. His analysands took him to a psychiatric hospital to be treated for psychosis. The psychoanalysis of the 12 analysands was abruptly interrupted, and Dr. Karl Menninger had to send some of his analysts from Topeka, Kansas to do effective crisis intervention for the abandoned analysands.

The first antipsychotic medication in Western Medicine was Reserpine, introduced as an anti-hypertensive by Dr. Rustom Jal Vakil, and as an antipsychotic by Dr. Siddiqui, in the early 1940’s. Both discoverers were Indian doctors, “British subjects” who published their findings in British journals. Reserpine was considered to have been “discovered,” though in reality, it had already been used for the same indications in the ancient Indian medical science of Ayurveda for many centuries. The drug was derived from the plant “Sarpagandha,” later given the English name “Sarpina.” This history is reminiscent of the “discovery” of digitalis. When I was a medical student and intern in India in the mid-sixties,

The disillusioned chairman of the medical school’s department of psychiatry, who had concluded that dynamic theories could not help the seriously mentally ill, wrote a book titled “The Freudian Delusion,” and in a few years was replaced. Around that time, the perceived voice of authority shifted from the state hospital superintendents to the psychoanalytically oriented academic psychiatrists.

Some people insisted that the mentally ill needed to be liberated from their “confinement.” This carried more

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weight for their rescuers than meeting their basic needs for housing, food, and a comfortable social environment, which they would lose overnight when they were discharged literally to the streets. This happened in the latter half of the 1970’s. For many, the state hospitals had been their home for 40 or more years. Many of them became homeless, as they could not adjust to the nursing home environments.

Despite all the biotechnological advances, most patients do not have access to good treatment. Social disparities are perpetuated by the governmental policies and those of the third-party payers, who resist paying on an equal basis for treatment of mental illnesses--including substance abuse.

There is a large population who would be better cared-for in long term hospitals. The 1500-bed state hospital where I, personally, had 300 patients under my care has only 120 beds today. What happened to the rest? What happens to all the patients who need these beds? Some are scattered on the streets as “homeless” or as nonviolent criminals incarcerated in the prison system.

One of the psychiatrist members of the steering committee responsible for the national policy for the care of the chronically mentally ill later expressed to me that he had deep regrets for the decisions they had made then.

He recognized that the alternative community care for the seriously mentally ill had not been well-planned prior to dismantling the state hospitals to primarily please those who gave enormous importance to the “liberty interest” alone.

Most of the mentally ill who get any care at all in the public sector psychiatry are getting it from Nurse Practitioners, PA’s, or PCP’s. None of these professionals are BoardCertified in Psychiatry. And there is not enough systematic planning for increasing the number of trained psychiatrists.

Gradually, power again shifted in academia, from Psychoanalysts to Biological Psychiatrists. “Neurosis” was removed from the “DSM” in the 1980s. Some people began to believe that there was a medication for every psychiatric illness and the cause of every psychiatric problem was a chemical imbalance in the brain. Every “abnormal” thought, feeling, or action must have a corresponding “abnormal” or misbehaving molecule.

More and more balancing and curative molecules were discovered and introduced in the care of the mentally ill.

“Mind” was dismissed from Psychiatry. Mental anguish of humans became brain disorders.

Even 130 years after Kraepelin, the classification in descriptive psychiatry is still based on phenomenology alone, rather than solid evidence of neurobiological or psychodynamic etiology, neural circuitry, etc.

What are the solutions? Below are some thoughts: Funds need to be utilized strategically, to not only attract candidates in large numbers who wish to be truly trained fully in Psychiatry, but to help also maintain a sustainable work force of them. There needs to be a central body with effective power to set clear goals and meet them over the next two decades. Psychiatric manpower is crucial; mass education of mid-level clinicians needs to be viewed as a transient band-aid to solve the needs of the mentally ill.

Many analysts started gravitating into Child and Adolescent psychiatry, where medications played a less dominant role and there was more room for psychosocial treatment modalities Most trainees graduated to become practicing biologically-oriented psychiatrists. Visits of 10 to 15 minutes did little for the emotional pain and discomforts emerging from loss of love, toxic interactions, loneliness or other psychological or social conflicts. The NIMH gave prominence to biological determinants. There is such a great shortage of psychiatrists with psychodynamic therapeutic skills, and similarly sensitive therapists or care givers, that there is more and more acceptance of midlevel practitioners lacking advanced psychiatric training.

Pressure needs to be placed on the health insurance industry and third-party payers to not only cover the true costs of care, but require that the psychiatric care be given by psychiatrists. Mid-level clinician care givers need to be under the strict supervision of psychiatrists, and their patients need to be in good hands when their treatment decisions call for a higher level of expertise.

Fees, reimbursement, and remuneration need to be commensurate with the educational qualifications, training, and experience. Patients must be clearly informed about their options so that they can make informed choices appropriate to the level of care they need and based on what they can afford. The mid-level clinicians must be clearly defined as physician-extenders, so prospective patients have a choice to select them at a lower cost. There is nothing wrong with the diluted “watered down” care so long as the patients have a choice and access to more competent care if they so desire.

The effects of these shifts can be seen in the recently “innovative” idea of providing a medical home to the chronic mentally ill. It is an “integrated care” or “collaborative model” under the guidance of a PCP, with access to a psychiatrist for consultation. Over time, the psychiatric services will be diluted, yet the patients may receive over-all better comprehensive healthcare.

Mental illnesses were not eradicated like smallpox, polio, or malaria. The mentally ill were simply redistributed in society. When they are hospitalized, they are confined in short-term, smaller institutions with revolving doors.

One encouraging example of this would be to open more facilities like the one being built currently in the Houston Medical Center – The UT Health Behavioral Sciences

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Center. This model incorporates a high-tech teaching facility and a 264-bed inpatient educational hospital (not revolving-door) where future physicians and specialists will be trained. As funding increases to build larger staterun facilities to accommodate the mentally ill, this sort of training hospital will enable a greater quality of care to address the huge and increasing mental health challenges. The country needs to be educated regarding the importance of Mental Health and the need for timely treatment of mental-emotional disorders. Radical changes in environmental, social and governmental attitudes towards mental health are what we need to demand from all stakeholders.

pharmaceutical companies in the form of grants and advertising revenue. Huge portions of the budgets of our academic departments and professional organizations are still financed by industry. Some people thought that “partnering” with the insurance industry and “Big Pharma” would sell out our patients and ruin Psychiatry. In many ways they were right.

The time we actually spent with patients became uncoupled from the amount of money we got paid as 90862 (Medication Management) became the most commonly used outpatient psychiatric visit CPT code.

Many practitioners saw 8-10 patients an hour, taking a cursory symptom-focused interval history and writing a prescription. Patients’ expectations of what psychiatrists offered plummeted. More psychiatric medications are prescribed now by primary care practitioners. Psychiatric nurse practitioners provide more episodes of psychiatric care now than psychiatrists. Vastly more psychotherapy is provided by non-psychiatrists. Leadership roles on behavioral health teams, institutions, and clinics are increasingly occupied by non-psychiatrists. A multibilliondollar wellness industry has grown up that purports to treat many of the same problems psychiatrists focus on.

What Happened to Psychiatry?

The Last 30 Years By: Thomas B. Franklin, MD I started my career during the socalled “Decade of the Brain”, when it was thought that the wisdom of psychodynamic psychiatry would be potentiated by stunning advances in neurobiology, psychopharmacology, and genetics. This would usher in a new age that was to be humane, effective, and integrated fully with the rest of Medicine.

Unfortunately, this promise was never achieved.

What does this all mean for the future of our profession? In the “near term”, we are in a transitional period, much in demand as a wave of retirements has created a need for more skilled diagnosticians and prescribers. Over half the psychiatrists in the US are over 60 years old. This is perhaps one of the best job markets for graduating psychiatrists ever. They are finding positions with high pay and good hours. They are practicing at the “top of their license” – a euphemism for prescribing for every patient while other people do therapy, run teams, and actually manage patients. In the “medium term”, Psychiatry will be swept along by strong forces. Mid-level practitioners will be providing almost all of the primary care and are already being used as attending clinicians on specialty psychiatric units in “top 10” hospitals. As there are fewer and fewer psychiatrists per capita, due to retirement and population growth, those left will become more expensive. This will bring even more mid-level practitioners into the field, who will do very well with the new standard of care that has evolved over the past 20 years – symptom-focused algorithm-based prescribing. Psychotherapy, when provided at all, will be left to mid-level practitioners. Those psychiatrists willing to do this work may do well individually, but as a profession we will continue to stagnate. There will be a few treatment centers available that will provide fully integrated biopsychosocial care for a while, but psychiatrists there will eventually also be sidelined. Most jobs will involve consulting to primary care or participating, but not necessarily leading, teams in psychiatric hospitals or behavioral health clinics. These teams will need us less and less. Private practice psychiatry will continue its decline as older psychiatrists retire and younger ones choose lucrative employment without the headaches of owning a business or dealing with increasingly challenging managed care and regulatory environments.

Today, American Psychiatry has failed on multiple levels, with more people suffering from disabling psychiatric illnesses, more suicides and overdoses, and less access to quality care than a generation ago. While other branches of Medicine successfully took on cancer, smoking, and other major public health problems, Psychiatry has remained flat-footed, despite the belief that we had more effective treatments available than ever. Psychiatry has become a sort of lame behavioral neurology. Partly this can be explained by managed care, as for-profit companies took advantage of our hubris and ignorance of business to essentially take away our power to treat our patients the way we thought would be in their interest. “Absence of evidence” for certain kinds of care, particularly for seriously ill patients, became “evidence of absence”. Rather than proving that time spent with highly trained, experienced clinicians and teams led to better outcomes, we fetishized neuroscience while our patients suffered. The stigma of having a psychiatric disorder – and our “self-stigma” as we fought to further medicalize Psychiatry – made us especially vulnerable. Today, only a fraction of the money is spent – as a percentage of the health care budget – on psychiatric care (as was true in 1980, but even more pronounced today), and much of it goes to pharmaceutical companies rather than direct patient care. Two generations of clinicians now have been trained not to think of what is best for the patient, but instead of what will get funded.

At the same time that managed care was devastating clinical work, academic psychiatry and our professional organizations were heavily influenced by corrupt

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One might optimistically point to recent advances such as the use of ketamine or psilocybin and say that this will be the vanguard of a new array of treatments for seriously ill patients. That may well be, but the venture capital behind it has already decided psychiatrists are not necessary.

The clinics are being run by nurse anesthetists and nurse practitioners.

psychiatric nurse practitioners can be turned out in as little as 5 years via accelerated BSN/NP programs.

Psychiatry at its best is a highly creative, difficult endeavor, but we are on the cusp of losing that forever if we do not take it upon ourselves to maintain awareness of these realities and put our energies into relevant and effective education and advocacy.

It’s hard to imagine a need for many psychiatrists 20 years from now. By then, computer holograms may even skillfully interact with patients to elucidate their symptoms and prescribe medication. People will prefer them to humans because they will not be as ashamed when describing their problems. Masters-level trained clinicians will have taken over Medicine as we move finally to some form of universally publicly- financed care. The notion that one would need 8 years of post-graduate education to treat mental disorders, or indeed work in the medical field, will seem antiquated. Those psychiatrists left will be involved in research and as expert consultants in particular areas. Society and the health care system will decide they don’t really need what we have become.

Dehydration: Therapeutic at the End-of-Life By: Steven Lippmann, M.D. Maintaining hydration is an important healthcare principle. Good physical and emotional health are enhanced by proper fluid and electrolyte balance.

However, there are times when full hydration is not desirable or even counterproductive.

Some patients who are dying can be comforted by some degree of dehydration. Besides diminishing discomfort, it can also be a means to shorten the process of dying.

There is a universal wish to maintain enjoyable lives, but not to prolong unpleasant deaths.

How might we change this? We must build a valuable product that we can uniquely provide. Then we must sell it to a public that is already skeptical of us. Having worked for 15 years outside of the mainstream of psychiatry in a (necessarily) private-pay service line, I can tell you that education, experience, and training matter: they matter greatly. Organized Psychiatry must take a stand on behalf of patients and quit taking money from entities that have consent decrees or have paid fines for criminal behavior.

We must put its maximum effort into creating a standard of care that harkens back to the biopsychosocial ideal. We must create model programs of care in communities and academic medical centers. We need to start moving money wasted on much of the basic science research into clinical studies that focus on what actually helps patients recover. We need to regain the trust of people by being much more skeptical of the pharmaceutical industry even if it costs us in the short run. We need to support leaders that will admit to past mistakes. We need to quit blaming outside forces and take on more responsibility as a profession. We need to unite the insights and knowledge of the past 50 years into one highly trained, highly effective profession whose real value is providing a powerful integration of neurobiology, psychology, and social science. We need to train a generation of psychiatrists competent to provide truly expert care, and we need to do it more cheaply and in less time.

For some sick people, being less than fully hydrated can attenuate nausea, vomiting, or diarrhea. With lower volumes of urine and feces, incontinence might diminish, and that would minimize skin breakdown. Dehydration may decrease dyspnea, coughing, and choking, and promote better pulmonary function. Less ascites helps breathing and movement, and less edema promotes global comfort. Keeping patients comfortable takes precedence when death is imminent. Of course, this needs to be done in accordance with every person’s own wish – never curb drinking and always keep patients’ mouths moist.

Reducing pain is another important goal, and dehydration facilitates tissue shrinkage. This is particularly good for neoplasms in confined spaces. Analgesic medicines, like opioids, often are more effective pain relievers when the body contains less water.

Terminally ill people may choose dehydration as a method to shorten life. It is a physician’s obligation to honor a patient’s autonomy over life and death choices.

People can elect to no longer eat or drink, and this can be maintained or reversed back-and-forth at their own discretion. It allows personal choice and control at the end of life. Despite dehydration plans, a person may decide to drink or to moisten the mouth for comfort and for the taste.

Psychiatric education is currently organized around the needs of institutions, not patients or trainees. The model of graduating students in mental health and requiring them to have 1-2 years of supervision after graduation has worked well for other mental health practitioners.

Medical school should be condensed to 3 years. General psychiatric residency should be 2 years followed by 2 years of work in the community under more senior psychiatrists. Taking 12 years after high school to train a psychiatrist is not sustainable, especially when

Here is how I became interested in this topic. Several years ago, my mother was dying of pancreatic cancer with a bowel fistula exiting her flank. She was in great distress, in her mid-90s. Pain was a huge problem, and remediation was not possible. With guidance from an oncologist and our family, a dehydration regimen provided

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a bit more comfort and a much shorter course.

Subsequently, my mother-in-law, in her later 80s and long-suffering with crippling degrees of Parkinsonism, was bedridden with exquisitely painful bedsores and had been praying for death nightly. With family input, a similar dehydration plan was offered, and it too facilitated a faster, less troublesome departure.

introducing numerous surgical techniques. He was admitted as a patient to the Butler Hospital because he was addicted to cocaine. At Butler, physicians then prescribed opiates to attenuate cocaine drug withdrawal, so he got “switched” from cocaine dependance to opiate addiction. Together with the Oxford internist, Sir William Osler, he was one of the founders of the Johns Hopkins Medical School. It offered excellent, up-to-date physician education.

Dehydration, particularly in older people, is not uncomfortable and it can rather quickly hasten death without pain, sedation, discomfort, or other distress. It avoids the aspect of someone committing suicide. It also removes physicians and/or family from facilitating a suicide or causing someone to die. Continuing a dehydration plan or deciding to start drinking fluids again remains completely elective at the patient’s own discretion and personal control. This selective method maintains autonomy and dignity at the end-of-life.

Here is a Louisville connection to the evolution of modern US medical education. In the 19th century, American medical schools were generally not as good as European ones. They were unregulated, often proprietary, and without academic requirements, faculty, or credentialing.

Providing quality medical education was not universally a primary goal until that time. Then, a Louisvillian, Abraham Flexner, was part of a movement that evaluated all the American medical schools, closed them, and only allowed them to reopen if they met the Johns Hopkins University role model for educating new doctors. Every medical school that reopened had to meet similar high standards of clinical healthcare and scholarship. That included having faculty on-staff in all specialties, providing care to patients, and actually teaching medical students. This reform greatly improved US medical training. Abraham Flexner Way, a road named in his honor, runs between our Jewish Hospital and the University of Louisville School of Medicine.

Butler Hospital, Abraham Flexner, & Johns Hopkins Some Notes on Psychiatric History By: Steven Lippmann, M.D. With restrictions on travel eased, we visited our eldest daughter in Rhode Island. A faculty member in Emergency Medicine at Brown Univeristy, she was our tour guide. Butler Hospital, now affiliated with Brown University, was among the first places she showed us in Providence. Founded in 1844, it is a huge institution sitting on a surprisingly massive, yet attractive, campus that houses numerous buildings – even a centuries-old farmhouse built in 1731. The hospital is named for the original financial donor Cyrus Butler who contributed the money together with Nicholas Brown to start this, the first dedicated psychiatric hospital in Rhode Island. Besides many in-patient facilities for psychiatry and addiction medicine, it also hosts a day hospital, services for social work, a wide variety of offices for other out-patient medical specialties, investigational facilities, and a courthouse. A network of campus roads and parking lots links the numerous buildings.

By the way, Johns Hopkins Medical School was originally conceived in the late 1800s to be funded with a big donation of railroad stock shares. It was to be a public hospital without race or other restrictions for patient admissions. However, a stock market decline left insufficient funds. The donor’s daughters agreed to help fund the new school, but if – and ONLY – If women students were to be admitted under the same criteria as men. The administrators initially refused, but, short on money, they finally agreed to consider female applicants in the same way as for males. Johns Hopkins then became the established role model for all US medical schools to copy. The above evidence a connection between Butler Hospital, Louisville, Johns Hopkins University, and all medical schools throughout the United States of America.

Butler Hospital is a base for Brown University’s Psychiatry Department and remains a famous, award-winning hospital. The focus is on psychiatry, addiction medicine, research, and movement disorders like Parkinson’s disease. They serve adolescents and adults; children, too, had been included, but these days they are hospitalized at another of Brown Universisty’s local, affiliated facilities. Butler is one of the primary sites for teaching psychiatry to medical students and residents especially when focusing on clinical practice. It was one of the first psychiatric hospitals in this country and maintains some prominence in psychiatry, clinically and at teaching.

New Hope for Combating Postpartum Depression ... and a Louisville Psychiatry Resident's Thinking By: Audrey Summers, M.D. & Steven Lippmann, M.D. Postpartum depression is an often-overlooked diagnosis.

Many women are depressed and/or anxious at their obstetrical checkups and/or postpartum follow up appointments; however, doctors might not recognize subtle mood changes at brief encounters. The Edinburgh Postpartum Depression Scale is a well-accepted

One prominent story connected to Butler is about Dr. William Halsted. He was an early leader in aseptic surgery, using anesthesia during operations and

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screening tool, but it is not often administered to women post-delivery.

A 32-year-old female who was 33 weeks pregnant with her second child was a recent patient I (Dr. Summers took care of in one our Louisville, Kentucky psychiatric inpatient units). The patient had tried to commit suicide and was struggling with severe peripartum depression.

Our team stabilized and optimized her medications; however, we wondered if one of these novel treatments could have improved her functioning much faster.

About 50% of postpartum depression (PPD) cases start when the woman is in the third trimester of pregnancy.

Unless the patient is overtly depressed, some physicians do not consistently consider psychiatric symptoms. Even when PPD is diagnosed, there are few treatment options that offer quick relief. PPD can become debilitating, especially following delivery when progesterone levels dramatically drop dramatically, and when women are adjusting to a significantly new lifestyle.

Adolescent Suicide During the Pandemic By: Sendhiul Raj Karmegam & Steven Lippmann, MD

Current treatment has included pharmacotherapy with serotonin reuptake inhibitor drugs (SSRIs and SNRIs) and other antidepressant medications. Such pharmaceuticals may take weeks to induce productive effects at elevating mood.

Concerns about the mental health of adolescents rose during the COVID-19 pandemic.

Public health safety measures like school closures, social disruption, pandemic fears, and less access to primary caregivers yielded much distress. Suicide-risk screenings evidenced higher rates than before the pandemic. The American Academy of Pediatrics declared this a child and adolescent mental health emergency in October 2021.

Brexanolone is a pharmacotherapy for faster-acting relief of PPD and it is effective in treating women suffering from PPD. This medicine is administered via a 60-hour intravenous infusion performed in hospitals or infusion centers. This intervention requires close patient monitoring and is expensive. The cost is near $34,000 for the drug even without the additional infusion and monitoring fees. Brexanolone also may cause potentially dangerous adverse effects including sudden loss of consciousness and/or sedation.

Emergency room contacts for suicide attempts in early 2021 were 50% higher among teenaged girls than during the same period in 2019. Adolescents accounted for a 6.5% share of all suicides in 2020, as compared to 5.9% in the previous five years. Average “boarding times” in ERs rose from 2.1 to 4.6 days; 60 % of those hospitalized were suicidal or had made suicide attempts.

Zuranolone is a recently developed oral form of Brexanolone and is administered as a 20mg or 30mg oral tablet once daily to counter PPD. Zuranolone is undergoing phase 3 clinical trials with reported clinical efficacy. Hamilton depression rating scores declined from baseline: 72% achieved over 50% symptom reduction response and 45% were in remission at a 15-day end point.

Somnolence and headache were the most common side effects but were not as frequent and less severe than documented during Brexanolone studies.

High placebo remission rates were observed as a major limitation to this investigation.

COVID-19 disproportionately affected people by race and ethnicity. Minority youth had less access to care, resulting in more depression, post-traumatic stress, anxiety, substance abuse, and suicide. Suicidal ideation was more frequent among Caucasian than in AfricanAmerican or Asian students, but the prevalence of actual attempts was higher among Native American ones.

Also, the children of frontline, essential workers suffered from increased isolation and abuse. A national Crisis Text Line service study of girls evidenced 50% more selfharm as compared to boys; the highest rates occurred in Kentucky, Arizona, and Tennessee.

Zuranolone and Brexanolone are gamma-aminobutyric acid-A (GABAA) receptor allosteric modulators and are structurally equivalent to allopregnanolone, a progesterone metabolite. The mechanism of action involves binding to GABAA receptors in synaptic and extra-synaptic clefts; yet the implications of such binding are not verified.

School closures had a negative impact on teenager’s social relationships. Amongst 9th–12th grade students, those who were well-connected had fewer mental health problems (28% vs 45%), suicide ideation (14% vs 26%), and suicide attempts (6% vs 12%) during the pandemic than less socialized students. Also, 7th-12th graders who were attending school virtually reported more emotional issues than those with in-person classes. Adolescents receiving virtual instruction reported more persistent depression, unhealthy days, and increased suicidal thinking than others.

There is evidence that Zuranolone exhibits a unique mechanism also with a rapid onset at reducing depressive symptoms. Unclarified issues remain, such as safety with breastfeeding, cost, and a timeline for prescribing approval. Further research might confirm that Zuranolone diminishes PPD symptoms, safely improves mental wellbeing, and helps PPD-affected women focus on what is most important: being a mother.

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Teenager suicide rates in rural areas generally did not differ much from previous years. Nevertheless, high school students in rural Kentucky had more mental health crises and personal struggles, like their counterparts throughout the country. As the pandemic went on, ruralcommunity adolescents began gradually to gain more access to mental health services via tele-medicine.

without chemical dependencies, evidenced no more dangerousness than the general population. Social, economic, and environmental issues have a stronger impact on acts of aggression than psychopathology.

The US has a much higher rate of homicide, gun-induced homicide and/or suicide, and accidental firearm deaths than other high-income nations. This trend has continued; weapon and ammunition purchases increase after mass shootings and/or potential governmental actions to limit firearms. The US also has the most permissive gun laws and the highest number of firearms per capita among similar countries. The 2017 Small Arms Survey, for example, revealed that we have approximately 121 firearms per 100 persons, while Canada, number two on this weapons possession list, was at about 35 guns per 100.

COVID-19 has presented us with multiple stressors – social isolation, remote learning, economic burdens, and substance abuse. The health care system is trying to deal with these. The higher adolescent suicide rate serves as an example of what we should be addressing. We still need to better recognize and understand the impact of the pandemic, particularly for youth and for minorities.

Mental Health & Gun Violence – What Are the Facts?

By: Srija Chowdary Vanka, M.B.B.S & Steven Lippmann, M.D

Based on data from the Institute for Health Metrics and Evaluation’s (IHME) Global Burden of Disease (2019) and the World Health Organization, the prevalence of psychiatric illnesses (that includes substance use disorders) is around 15%, this amounts to around 1 in 7 people. The reported prevalence of mental disorders in the US is almost 17%. Putting this into perspective: the United Kingdom’s prevalence is about 15%, Australia’s is 19%, and Switzerland’s is 17% and Ireland’s is nearly 18%. But carnage from firearms in the US is much more common.

The rate of gun violence in the United States is rising. We need to devote urgent attention to this public health crisis.

In Louisville, where the university hospital has a Trauma1 Level Emergency Medical Department, a suicide attempt with a gun is fatal nearly 80% of the time. About 2/3 of the fatalities occur quickly, usually at the scene.

(Being shot by someone else yields a fatality rate closer to 20%.) The ER staff notes a surprising number of people who claim someone else has shot them, though they suspect the patients have done it themselves.

Policies that primarily focus blame on persons with psychiatric disorders will not significantly diminish the rates of violence. They might also create more difficulties by exacerbating irrational fears and more stigmatization.

Many violent events are committed by alienated, angry young men who feel rejected, frustrated, neglected, and aggrieved. They are not diagnosed as mentally ill, but they harbor powerful emotional turmoil. Some of their feelings are reinforced by dangerous messages that encourage using guns to act on an issue or seek revenge.

Some are suicidal (at least transiently) and see acting violently as a way to die by shooting themselves or being killed by police. For such individuals, police may be an encouragement, rather than a deterrent, to act (“suicide by cop”).

There is a common misconception that psychiatric disorders are a major precipitant for gun violence; yet, that is incorrect. Some of the misrepresentation might be attributed to sensationalist presentations in the media and/or on societal stigma against people with mental illness.

The National Institute of Mental Health studied 10,024 subjects in an Epidemiologic Catchment Area investigation about the prevalence of violent behavior in adults with or without a diagnosable psychiatric disorder.

The 1-year population risk of aggression associated with serious mental illness was approximately 4%. Thus, nearly 96% of societal violence is without any association to such conditions. The major risk factors for increased rates of dangerous behaviors included younger age males, lower socioeconomic status, and substance abuse.

We need to create steps to mitigate their distress and to foster safer coping skills. Everybody benefits from addressing this critical issue. The most valuable assistance might come from diminishing abuse, neglect, unemployment, isolation, bullying, homelessness, and substance abuse.

There are other ways to further mitigate gun violence.

Productive areas for potential action include addressing the sheer number and safe storage of firearms. Initially, we might place more focus on limiting access to firearms by persons with previous dangerous behaviors or records of domestic violence.

The MacArthur Violence Risk Assessment Study also investigated violence among psychiatric patients, examining over 1,000 after discharge from a hospitalization. At 1-year follow-up, substance abuse was the factor most associated with a higher rate of aggressive behavior. Those with mental illnesses, but

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Suicidal Impact of Firearms During COVID-19 on Patients & Physicians By: Nishi Chandrasekaran, M.B.B.S. & Steven Lippmann, M.D.

reportedly experience suicidal ideation at a rate of 7%, while the community risk is reported at 4%.

Physicians seeking care for themselves should not be stigmatized as showing weakness, and this should not automatically jeopardize professional licensure. Attending to medical, emotional, substance abuse, and/or other difficulties benefits their patients and themselves.

Professional organization hotlines, self-help groups, and impaired-physician state board committees can provide additional assistance.

Gunshots accounted for 52% of the 45,979 deaths by suicide in the U.S.A during the COVID-19-pandemic year of 2021. Self-induced firearm wounds cause high lethality, while many other attempts allow a chance to rethink the impulse and/or call for help. Beyond healthcare delivery to patients, this association between firearms and suicide has an impact too, on physician suicide risk profiles.

Much as “do no harm” relates to patients, the same applies to practitioners. We need to reach out to others when we could benefit from help. “Doctors who treat themselves have a fool for a patient.”

While social distancing curbed the spread of coronavirus infections, it also harmed mental health generally, due to the unintended consequence of interpersonal isolation, with problems in employment, schooling, access to services, and/or finances. Substance abuse rates also increased dramatically. Another dangerous after-effect of this pandemic was the rise in gun purchasing – 2.5 million non-gun owners reportedly bought firearms. New owners are more inclined toward ending their lives when compared to others. The surge in buying firearms during the pandemic is probably related to rising existential crises, anxiety, fear, depression, and/or drug abuse.

Nitrous Oxide Abuse: Just Laughs, Or Something More Sinister?

By: Clayton Olash, B.A., Syed A. Abbas, M.D, M.B.A., & Steve Lippmann, M.D.

Nitrous oxide (N2O), colloquially known as “laughing gas”, is recognized for its usage as an anesthetic. However, less-known are its potentially dangerous neurological and/or psychiatric side-effects following medical administration, long-term occupational exposure, and/or recreational abuse. It can cause weakness, paresthesias, ataxia, and psychosis--persecutory delusions, auditory hallucinations, and emotional lability.

Firearm ownership is associated with depression and the risk of suicide. Between 2004 – 2011, individuals with depression and substance abuse were also likely to own guns. Because of these risks, physicians should inquire about firearm access among patients under heightened stress. This applies especially for persons with substance abuse and psychiatric issues, like depression or anxiety.

Always consider this agent as a possible etiology for psychiatric signs and symptoms. N2O is one of the top five inhalants most used by adolescents in the USA. University students in New Zealand admit that 12% of them had used nitrous oxide recreationally. Abuse was first reported in the 19th century with “laughing gas parties.” It is used recreationally due to its potential to cause hallucinogenic, dissociative, and euphoric effects.

Furthermore, it is readily available in industry and as a propellant in food canisters, available at supermarkets.

Proper firearm and ammunition storage is a safety factor.

Keeping guns locked away in the attic and bullets locked up in the basement diminishes impulsive shootings. While many weapon owners utilize such secure storage, those more inclined toward ending their lives do so less often. It is important to teach about and advocate for such safe, protective storage to our patients and to do it ourselves.

Firearm access should be removed from anyone with depression, drug use disorders, or a history of dangerousness to themselves or others. Those with serious emotional, neurological, physical, chronic pain, or other disabling conditions may benefit from doing this, too. The same also applies often to people who are societally alienated and/or feel victimized and those undergoing a major or acute stress issue; families (and sometimes local authorities) can be helpful in at least temporarily limiting weapon access.

Its neurological effects might be induced through inactivation of vitamin B12, resulting in a functional vitamin deficiency. The irreversible oxidizing of the cobalt I (Co+) form of cobalamin to Co inhibits methionine synthase.

That causes the buildup of substrates that provide for atypical fatty acid synthesis in the myelin sheaths of neurons. A secondary pathway may result from the absence of methionine synthesis, yielding a lack of appropriate methylation of myelin membrane phospholipids.

Neuropsychiatric symptoms resulting from N2O abuse could result from increased production of nitric oxide via presynaptic nitric oxide synthase enzymes.

This leads to accumulation of peroxynitrite, which is thought to exhibit neurotoxic effects as a non-competitive N-methyl-D-aspartate (NMDA) antagonist.

The pandemic has also exacerbated worry about physician burnout. Doctors have a higher rate of suicide when compared to the rest of the community. Males have a 40% greater likelihood to end their own lives; women physicians evidence over twice that risk. The most common method of death – related to substance abuse – is associated with a firearm. Doctors in this country

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The most effective treatments for nitrous oxide neurotoxicity is the removal of the nitrous oxide source, administration of high dose intravenous vitamin B12 or thiamine, and/or prescribing neuroleptics. Prolonged psychotic symptoms have also been reported, especially in patients with a primary psychiatric illness.

2) Another consideration is that immunomodulatory medications, such as high-dose corticosteroids, prescribed to treat primary infections, can produce psychoses. This effect is usually observed following short course pharmacotherapies. Yet, in the majority of COVID19 cases, the psychoses developed either before steroids were started or long after they had been discontinued.

Consider a N2O-induced etiology in cases of unexplained psychosis and be familiar with the therapeutic options.

Although this issue appears to be important, its extent remains unknown. The lack of reliable statistics could be due to simple under-reporting or even over-reporting.

More research needs to be done.

COVID-19 Induced Psychosis?

By: Neil Kidambi, M.D., Omar Elsayed, M.D.,& Steven Lippmann, M.D. COVID-19 has caused many to look at its influence on mental health. Rates of anxiety, depression, insomnia, and stress disorders are rising. Recently, long COVID – composed of physical and neuropsychiatric symptoms that can last for months following resolution of infection – has been described. One uncommonly recognized aspect of COVID-19 is the occurrence of new-onset psychoses, without any preexisting psychiatric illness.

Muruga Loganathan, MD Dr. Muruga Loganathan, currently serves as Assistant Professor, Division of Child & Adolescent Psychiatry, UT Southwestern Medical Center, Dallas, TX. He obtained his medical degree from Stanley Medical College, India. He completed his psychiatry residency and child fellowship in Allegheny Health Network, Pittsburgh. He started his career as an outpatient child psychiatrist and served as a medical director in a partial hospitalization program serving rural Pennsylvania for 5 years. Later, he was a faculty member at West Virginia University, Morgantown for 3 years as Assistant professor of psychiatry; he managed consultation liaison psychiatry and served as medical director of inpatient psychiatry. He received WVU BMED Chairman Teaching Award in 2021. Recently, he moved to Dallas, joined UT Southwestern Medical center as faculty. He is now playing an integral role in managing a child psychiatry workforce expansion program and child psychiatry access network, part of Texas Child Mental Health Consortium. He is passionate about helping children and teaching students, residents, and childfellow physicians. He is interested in childhood depression, suicide, and impulse control disorders. He is actively involved in clinical research and wrote many clinical review papers. He is a member of both the APA and American Academy of Child & Adolescent Psychiatry.

He likes to travel and is interested in soccer and badminton.

Since the onset of the pandemic, several reports of patients suffering a brief psychosis without any personal or family history of mental disorders have been documented – up to 6 months after they had been hospitalized with severe COVID-19 illness. Some examples, include: a 36 year old woman, presenting with persecutory delusions and decreased sleep, who responded well to olanzapine and lorazepam. A 55-yearold female with no prior psychiatric history developed a severe psychosis three weeks after COVID-19 recovery; remission was achieved following treatment with haloperidol and valproate. A case series of three individuals, ages 30-34, evidenced a first-onset psychosis with delusions, bizarre behavior, agitation, and disorganization. They responded to sub-antipsychotic doses of quetiapine in addition to clonazepam, insinuating that the episodes might be self-limited. Many others are documented, presenting similarly and responding to low doses of risperidone, haloperidol, clonazepam, lorazepam, mirtazapine, and sertraline. Only one of the subjects received steroids to combat COVID-19, mitigating the possibility of a steroid-induced psychosis.

It is unclear how these psychoses develop. However, a few theories have been formulated.

1) The most prevalent one describes an immunemediated inflammatory response. The virus is postulated to be neuroinvasive, like some other respiratory pathogens such as influenza and severe acute respiratory syndrome (SARS). It directly invades the brain, leading to cytokine dysregulation and causing neuroinflammation.

The blood-brain-barrier is also compromised, leading to monocytic infiltration, enhancing neuroinflammation, and disrupting neurotransmission.

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(especially the state hospital system). Dr. Tuck continues to pursue these interests since starting residency at Duke in 2019. He recently started a 2-year fellowship in the APA Edwin Valdiserri Correctional Public Psychiatry Fellowship. After graduating residency, he plans to work in an academic setting focusing on the treatment of individuals with serious and persistent mental illness.

Marina Nikhinson, MD Dr. Nikhinson is a board-certified psychiatrist with advanced training in psychodynamic psychotherapy, mentalization-based therapy, dialectical behavior therapy, and the treatment of mood and personality disorders. She is a master-trainer in the general psychiatric management of borderline personality disorder. In her decade-long tenure as an attending psychiatrist at the Retreat at Sheppard Pratt, the premiere program of the prestigious Sheppard Pratt Hospital, Dr. Nikhinson became a national leader in the treatment of people with complex psychiatric, psychological, and substance use disorders.

Eveleigh Wagner, MD Board-certified psychiatrist, Dr. Eveleigh Wagner, received both her undergraduate degree and Doctor of Medicine from Emory University in Atlanta, GA. She then moved to Nashville, and completed a psychiatry residency at Vanderbilt University Medical Center. Following residency, she became board certified and joined the Mount Auburn Psychiatric Group in Cambridge, Massachusetts specializing in psychopharmacology and ECT, as well as, Women-Focused and Geriatric Psychiatry. In 2022, Dr. Wagner returned to Middle Tennessee, and joined the NeuroScience & TMS Treatment Center team in the Franklin Road, Brentwood location. Her professional interests include helping patients with treatment-resistant depression and anxiety disorders, including posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD), and using interventional treatments to help treatment resistant patients (TMS and Esketamine).

She enjoys working with patients to help create treatment plans that meet their individual goals."

Dr. Nikhinson is a graduate of the Psychoanalytic Studies Program at the Washington-Baltimore Center for Psychoanalysis and is a faculty member in the University of Maryland School of Medicine. She is a founding member of MindWork Group and serves as its Executive Vice President and Chief Operating Officer. Most recently, Dr. Nikhinson has worked to develop an innovative new program at MindWork Group which offers intensive outpatient treatment services with a focus on sophisticated group and individual psychotherapy

Jonathan Scarff, MD A native of North Carolina, Dr. Scarff graduated from medical school from The Brody School of Medicine at East Carolina University and completed psychiatry residency at University of Louisville in 2013. After practicing at a Veterans Affairs clinic in Spartanburg, SC and later at Fort Lee, Virginia, he returned to Kentucky and currently works for Veterans Affairs in Lexington. He enjoys learning about history of both medicine and psychiatry.

James C. West M.D. Dr. West is Associate Professor of Psychiatry and a Scientist at the Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences.

He earned his Bachelor of Science in Engineering from the U.S. Naval Academy and his M.D. from the University of Michigan Medical School. Dr. West is board-certified in psychiatry and a distinguished fellow of the American Psychiatric Association. He is a retired Navy psychiatrist and served as an embedded provider with the U.S. Marine Corps in Iraq and Afghanistan. He currently serves in the APA Assembly as Area 5 Deputy Representative and is a member of the Committee on the Psychiatric Dimensions of Disasters. His professional interests include promoting safer storage of firearms as a suicide prevention measure, sustaining the resilience of disaster workers, promoting embedded systems of care, and translating understanding of the biological underpinnings of PTSD into more effective treatments

Andrew Tuck, MD Andrew Tuck, MD is a PGY-4 in Psychiatry at Duke University Medical Center. Originally from Michigan, he moved to New York City for medical school at Columbia University, where he engaged in a variety of psychiatric research projects and developed current interests in forensics, addiction, and public psychiatry

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LETTER from the EDITOR: It’s a Big Problem Choosing to Do a Little By: Bruce Hershfield, MD I can’t say I was surprised by the Washington Post article a few weeks ago that described the awful situation in ER’s in Maryland, where patients can wait weeks for admission to a psychiatric bed. The example they used was of an adolescent who spent 76 days there before being admitted. Many of us have known for years that it’s been a problem. There has never been a big push to create the beds that would alleviate it – even when the money has been available.

IN MEMORIAM: BRIAN CROWLEY, MD By: Bruce Hershfield, MD Dr. Brian Crowley, a well-known and esteemed member of the Maryland Psychiatric Society and the Southern Psychiatric Association, died on July 17th at age 89.

If so many of us knew about it, why did it take an expose to bring it to the public’s attention? We are supposed to be the leaders in the mental health field. That means we are supposed to be aware of the problems and then try to do something about them. That includes the big ones. For example, the inability of most people to access our services. Or the replacement of psychiatrists by counselors who can’t possibly help patients with serous disorders without medications they can’t access because they never see physicians. The long-term problems in state hospitals. The homeless mentally ill (particularly now they have easy access to weapons).

Originally from New York, he attended Washington & Lee and then graduated from the Yale School of Medicine. He trained at St. Elizabeth’s and graduated from the Washington Psychoanalytic Institute. He practiced for about 60 years – until very shortly before he died – earning a reputation for his work in forensic psychiatry and serving as an expert witness. He was Chair of the Department of Psychiatry at Suburban Hospital in Bethesda for two terms. He was in the Navy and Navy Reserve, attaining the rank of Lieutenant Commander, and for 19 years contributed to the efforts at Walter Reed, where he did research on PTSD.

I believe most psychiatrists want to make the world a better place. What are we supposed to do?

We can join together in groups like the SPA, the APA, and the AMA.

He held teaching positions at the Uniformed Services University of the Health Sciences and George Washington University School of Medicine, and also at the law schools of the University of Maryland and at Catholic University. He was also an accomplished writer, contributing many important statements on the MPS e-mail list and also articles for Southlands.

As individuals, we can write letters to the editor. We can vote and donate money to candidates who are interested in doing something about mental health issues. (But very few seem to focus on this.) We can support candidates within our professional organizations who promise to address them. (But SPA elections are not contested and the APA’s never seem to be based on significant policy differences.)

Active in psychiatric organizations, he was President of the Washington Psychiatric Society in 1996 and served two terms on the APA Board.

We can insist on bringing these issues up within our organizations. For several years, the SPA has had a seat in the APA’s Assembly. I believe we need to create some mechanism so our Executive Council can periodically identify items to refer to Mark Wright. He could then consider writing Action Papers for the APA. This would fit in with one of the roles the SPA could adopt, as the conscience of our profession. (The smaller, less political group, keeping an eye on the larger one, for the good of all.)

Leonard Hertzberg, MD said of Dr. Crowley: “My friendship with Brian extends beyond 40 years, when we were on the Clifton T. Perkins staff and attended meetings at The American Academy of Psychiatry and the Law (AAPL) and our Chesapeake Bay Chapter. He was a highly competent clinician in his practice and his forensic work. He was warm, kind and witty. His wife, Natalie joined with him at meetings and also was a good friend.

Brian was an expert witness at the John Hinckley trial and his presentations about his testimony were memorable. I last saw him in April and, although he was 89, he was still active with his practice and planned to attend the upcoming annual AAPL meeting in October.

If we don’t do something, then we continue to be a part of the problem.

Edmund Burke said about 225 years ago that “Nobody ever made a greater mistake than he who did nothing because he could only do a little.”

I was fortunate these many years to have Brian as a mentor and friend.”

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SPA OFFICERS 2022-2023 President: Thomas Franklin, MD President Elect: Mary Jo Fitz-Gerald, MD Vice President: Rodney Poling, MD Secretary-Treasurer: Raymond Kotwicki, MD Board of Regents, Chair: Lauren Pengrin, DO Board of Regents, 2nd Year: Felix Torres, MD Board of Regents, 1st Year: Chasity Torrence, MD APA Assembly Representative: Mark Wright, MD Immediate Past President: David Casey, MD Executive Director: Janet Bryan

SAVE THE DATE FOR THE 2023 ANNUAL MEETING: Huntsville, Alabama Partnering With the Alabama Psychiatric Physicians Association October 11 – 15, 2023 The Westin Huntsville, Huntsville, AL

“Southlands” articles represent the views of the authors and are not official positions of the Southern Psychiatric Association. Comments and Letters to the Editor are welcome and should be addressed to the Editor at BHershfiel@aol.com (Bruce Hershfield, MD, 1415 Cold Bottom Rd, Sparks, MD 21152) “SOUTHLANDS” EDITORIAL ADVISORY BOARD William Greenberg, MD Steven Lippmann, MD Jessica Merkel-Keller, MD Denis J. Milke, MD Editor: Bruce Hershfield, MD Assistant Editor: Janet Bryan

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