Southlands December 2023

SOUTHLANDS

The Newsletter of the Southern Psychiatric Association Volume 9, Number 2

December 2023

Article Title

Author

The Future of Psychiatric Practice: A Follow-Up

Thomas Franklin, MD

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Welcome Home!

Mary Jo Fitz-Gerald, MD

2

Executive Director Column

Janet Bryan

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Report From the APA Assembly

Mark Wright, MD

3-4

What They Said in Huntsville

Bruce Hershfield, MD

4-6

What it was Like to Testify to Ireland’s Parliament about Assisted Suicide

Mark Komrad, MD

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Interview: Paul Nestadt, MD

Bruce Hershfield, MD

6-8

Ageism & Implied Bias

Jenny Boyer, MD

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Artificial Intelligence (AI) in Psychiatry

Harold M. Ginzburg, MD, JD, MPH

9-10

The Problems of A-I Solving Issues in the Care of Demented Patients

Harold M. Ginzburg, MD, JD, MPH

10-11

Let’s Be Clear About Medical Directors

Shree Vinekar, MD

Physician Attitudes Towards Mental Health & Suicide

Tara Tamton, DO; Audrey Summers, MD; Ali A. Farooqui, MD

11-12

The Challenges Facing Physician Mothers

Sumeyra Baskoy, MD; Steven Lippmann, MD

12-13

Suicide Upsurges Surrounding The COVID-19 Pandemic

Kshetra Challapalli, MD; Steven Lippmann, MD

13-14

Learning Empathy & Professional Cooperation While on Psychiatry

Azzam Malkawi, B.A.; Mustafa Mohamed, B.S.

14-15

Mental Health and Miss Kentucky

Ankita Nair, B.S.

15

A New Era of Authentic Social Media

Ankita Nair, B.S.

15-16

Fit-Twin & AI: Can it Enhance Psychiatric Care?

Muhammad Sulaiman, Ph.D.; Amal Mumtaz, MD

Intranasal Esketamine Spray as Emergency Suicide Prevention

Rana Anwar, MD; Steven Lippmann, MD

16-17

What About Huntington’s Disease?

Rana Anwar, MD; Steven Lippmann, MD

17-18

Loneliness: What Our Surgeon General Says To Us

Amrit Kahlon, MD; Adil Khan, MD

18-19

Addressing the Problem of Isolation after COVID-19

Jonathan Ludwig, B.S., Steven Lippmann, MD

19-20

My Journey of Recovery

Viktoria Shihab, MD

Nalmefene: New Opioid Overdose Reversal Drug

Moji Lawson, M.S.; Steven Lippmann, MD

20-21

Donanemab: A New Alzheimer’s Treatment?

Chase Bauman, B.S., and Steven Lippmann, MD

21-22

Welcome New Members

Dan Dahl, MD; Ali Farooqui, MD; Larry Miller, MD

22-23

In Memorium: C. Duane Burgess, MD

Bruce Hershfield, MD

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Letter from the Editor: Where is Everybody Else?

Bruce Hershfield, MD

23

Save the Date:

September 11 – 14, 2024 in Chattanooga, TN

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2024 Annual Meeting

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Page

11

16

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The Future of Psychiatric Practice: A Follow-up By: Thomas Franklin, SPA President 2022-2023

The mental health of our nation, by several ways of measuring it, has declined significantly in the past 20 years, with suicides and psychiatric disability skyrocketing. We all know that training and experience matter, and that programs with highly trained practitioners with the time to treat people intensively produce better outcomes. But there is very little research going on that clarifies it so that it is widely accepted. What we are doing is failing.

At our meeting in Alabama we had a lively discussion of the future of psychiatric practice, including some potential scientific breakthroughs and also changes due to artificial intelligence and the transition to psych NPs/PAs providing most of the direct care. The idea that the standard of care generally was lower with less education and training was clearly endorsed. It was also commented on that our boards and membership associations seem more engaged in raising revenue through more and more odious certification requirements, rather than taking on this issue. More and more of our clinical work is being performed by practitioners who claim they can do it more cheaply. A few wiser folks reminded us that the death knell of psychiatry has been predicted before, and we are still here.

Our associations and departments of Psychiatry need to sponsor more studies about what works – and with what providers. They need to vigorously advocate for the resources to provide this care. Incentives to create blockbuster drugs are certainly firmly in place, despite their dubious benefit in many cases. What sort of incentives exist to put up clinical programs that actually reduce the level of disability in communities by providing effective care?

With the aging of the psychiatric workforce and the fact that NPs are providing over half the Medicare psych visits, it may be too late. Especially with A-I right around the corner. In the past. our profession adapted and stayed relevant. It’s hard to see how that will happen this time. The mental health care of our country has gotten much worse and is being handed over to practitioners with far less education and training than psychiatrists have.

An article in the Washington Post on Nov 19 reminded me of the discussions we had. https://www.washingtonpost.com/investigations/interactiv e/2023/home-birth-midwife-karen-carr/ It is about a nurse-midwife who had a bad outcome resulting from a failure to carefully monitor the fetus during a complicated delivery. The OB/GYNs interviewed for the story were aghast at the care that was provided, which they said was far below the standard expected of them. The nurse, though, when brought before the board of nursing, was judged by the standard of care of other nurse midwives. She ended up keeping her license because basically there was no standard of care in their profession for carefully monitoring the fetus. She is still practicing here in Maryland despite a number of bad outcomes.

Welcome Home!

By: Mary Jo Fitz-Gerald, MD SPA President 2023-2024 It’s a good idea to find mentors where we can. The best places are networking events where we feel comfortable. They feel like “home!”

As more and more treatment across our medical system is provided by nurses with a lower standard of care, or no standard of care, how are we to respond as physicians?

How should our boards and professional organizations respond?

I joined the APA and our local district branch when I was a trainee. I later became a member of the Executive Council of the Louisiana District Branch. It was my first professional “home.” I had friends and “mentors” in the organization. I still credit Dudley Stewart and Aretta Rathmell for my involvement with the APA. Later, Mark Wright, Mary Helen Davis, and Phil Scurria were my guides and friends with the Assembly.

We have recently spent billions of dollars studying neuroscience. It would have been much more helpful to have tried answering the questions about what works and doesn’t work with actual patients in the community – and what sort of education and training does it take to provide this care effectively. This research would be relatively easy if we had the political will to do it.

As a faculty member and training director, I had another – the American Association of Directors of Psychiatry Residency Training. Its listserv and meetings were invaluable sources of information on the latest rules and regulations. I looked forward to seeing friends again every year.

It’s curious how we deify evidenced-based Medicine, while we shift around practitioners, systems of care, amounts paid for care, censuses, and myriad other variables with no research at all. If you want to spend a dime to get something started, it takes a decade of papers to justify it, but if you want to cut something you just do it and see what happens.

As my roles in the academic medical center changed, so did my “home” professional organizations. These were invaluable for promotions, making friends, and garnering new knowledge. These organizations and their members

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have been my best source of support, encouragement and guidance. While there were times I missed the annual meetings, I knew I could count on these folks if I needed advice on my career.

Report from the APA Assembly By: Mark S. Wright, MD SPA Assembly Rep The APA Assembly met in Baltimore on November 3-5 – the first fall meeting in person since the beginning of the pandemic. In addition, PRMS hosted a reception for Assembly members and SPA members.

Now, the Southern is my “home.” A lot of my mentors from other organizations are here. The meetings are always informative, pertinent to my current practice, and a lot of fun. The group is always congenial and welcoming.

Here is a summary of the Assembly’s actions:

I am looking forward to meeting, and working with, all of you during my year as president. My goals will be to increase opportunities for networking for members who are on all levels of psychiatric practice. If you have any ideas for the organization, or would like to join a committee please let Janet Bryan or me (maryfitzgeraldmd@outlook.com), know. And above all, I want to welcome all of you “home.” The SPA can be a source of career guidance, providing leadership opportunities and identifying mentors.

The APA will develop guidelines towards preventing patient assaults on mental healthcare employees in psychiatric healthcare settings.

The APA should release a position statement on the importance of removing ECT as an exclusion to Advanced Healthcare Directives.

It approved a Position Statement that psychiatrists who identify patients as receiving no primary care, or lacking sufficient primary care services, can provide them care for common medical conditions where appropriate – based on competencies, local resources, and patient preference.

Welcome to our home.

Executive Director Column By: Janet Bryan

The APA will delegate a task force to collate the empirical data about dangers of unrestricted access to over-thecounter acetaminophen, and that the APA will advocate that the FDA and other relevant government agencies to restrict access to large quantities. The APA is to work with current awareness campaigns and interested parties to develop public outreach and education on the danger of acetaminophen overdose.

The Annual Meeting in Huntsville with the Alabama Psychiatric Physicians Association was an amazing event. There were 118 attendees, and the exhibit hall was full with 21 tables! The scientific sessions were inspiring (be sure to read Dr. Bruce Hershfield’s article recapping the discussions), the evening at the U.S. Space & Rocket Center was unforgettable – especially dining under the Saturn V Apollo moon rocket – and we ended with a Farewell Dinner Gala and dancing on Saturday evening.

The APA develop a position on the use of the word “Carceral” with respect to Correctional Psychiatry in APA documents. Also, that it develop a resource document to serve as a guideline on person-centered language related to people who are incarcerated.

Mark your calendar for next year’s Annual Meeting with the Tennessee Psychiatric Association at the Westin Hotel in Chattanooga, from September 11 – 14. It’s not too early to begin connecting with potential exhibitors – please send me information for anyone who is interested. The Program Committee is already working on speakers for the meeting.

The Council on Addiction Psychiatry presented a position statement on contingent management treatment of stimulant use disorder. It is the position of the APA that: Increased training for, access to, and implementation of evidenced-based contingency management is needed for the treatment of stimulant use disorder. Policy changes should be made to address the regulatory and legislative barriers to implementation of contingency management,

Dues notices were mailed in November and are due in January. If you did not receive a notice, please contact me at jbryan@sheppardpratt.org.

Funding agencies should support research on the mediators of successful community-based implementation of contingency management.

The most exciting project in the works is the redesign of our website. We are planning for it to be up and running by the end of January or early in February. Once the site is complete, I will send an e-mail to all our members.

A position statement regarding Opiate Overdose Education and Naloxone Distribution (OEND):

Wishing everyone a safe and happy holiday season.

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The APA and the American Academy of Addiction support efforts to expand access to overdose education and naloxone distribution for individuals and communities at elevated risk for opioid overdose, as well as bystanders, family members and those who may be in a position to respond to an opiate overdose.

one in-person visit for patients receiving controlled medications, and told us it is still being waived, postpandemic. She talked about HIPAA requirements and pointed out that insurance companies do not have to defend “illegal acts”. She advised us to find out where a patient actually is during a telepsych visit, in case we need to ask the police to intervene. Document that the patient is consenting to possible aspects of the visit (like being recorded). She told us that Medicare is planning to require an in-person visit within 6 months of starting treatment (and then on a regular basis). There are times when you may have to insist on seeing the patient in-person, like when there are tics or a significant weight loss, or possible pregnancy.

APA supports: 1. making naloxone available over the counter.

2. directing funds toward the purchase of naloxone for community-based OEND. 3. naloxone access laws to protect those who administer, prescribe, or dispense naloxone.

4. Good Samaritan/medical amnesty laws to encourage the use of naloxone and enable people to contact authorities for assistance during overdose emergencies without fear of arrest or prosecution.

She was followed by Dr. Chasity Torrence, who lectured about the ABPN’s continuing education process from an ECP perspective. She explained that the Board audits 5% of its ongoing diplomates per year. It requires documentation in 4 areas: professionalism & professional standing, lifelong learning/self-assessment/patient safety, assessment in knowledge, judgment & skills (since ’22 you can choose periodic re-examinations, or else read 30 articles in a 3-year period and answer questions about them), and Performance in Practice. The last one of these requires a clinical module or a feedback module every 3 years. This feedback can come from patients, or peers or other providers. The clinical modules have to be Boardapproved or Joint Commission-approved. The process costs $175 per year.

The Assembly passed a resolution, authored by Dr. Jenny Boyer, that the APA develop policy and interventions specifically addressing Ageism as a part of it’s equity policy.

It passed an Action Paper that APA work with key partners to advocate that CMS revise the existing measure for psychotropic prescribing in nursing homes to ensure nursing home residents have access to medically appropriate treatment.

It supported an Action that restores two in-person meetings a year.

Next, Drs. Glenn Treisman and Edward Lewis, III, gave a panel presentation concerning Substance Abuse. It was pointed out that after prescription opioids were restricted recently, overdoses increased 15 – 30%. A distinction was drawn between patients who are “reward-sensitive” and those who are “consequence-averse”. There was discussion of psychosis following marijuana use: there is a 2 – 10 fold increased risk of schizophrenia in patients from genetically-vulnerable families when they are exposed to it. People who use it during their developmental years suffer an average IQ loss of 7 – 9 points. They talked about a tranquilizer called xylazine that is sometimes mixed with fentanyl and about how useful buprenorphine has proven to be.

It asked that the APA designate a staff member to be the point of contact for members in training.

It passed an Action Paper that the APA make a major effort to update and improve visibility of its auto renew option to simplify membership renewal.

It endorsed a position statement on contingency management for the treatment of Stimulant Use Disorder.

It endorsed a pilot program creating equitable opportunities for the APA Fellowship program for international medical students.

The last lecture of the day concerned neuro-psychiatric manifestation of systemic lupus – by Dr. Shivani Malhotra.

Cognitive dysfunction associated with the disorder can include defects in executive functioning, memory impairment, and concentration problems. Depression is one of its most common NP manifestations – probably secondary to neuro-inflammation and immunedysregulation. Delirium can occur in 4 – 7% of SLE patients and “lupus psychosis” in 2 – 11%. Typically, treatment consists of high-dose steroids, but antipsychotics are also used sometimes. If they are, they should be continued for 6-months – one year after the acute episode.

The Assembly will meet again in May. Please let me know if you have an issue you would like to see me address.

What They Said in Huntsville Notes on the Lectures 10/12/23 - 10/14/23 By: Bruce Hershfield, MD After greetings by the presidents of the SPA and the APPA, Donna Vanderpool, JD, who is Director of Risk Management for PRMS, gave a “Telepsychiatry Update”.

She described the 2009 Ryan Haight Act, which requires

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On October 13th, Dr. Godehard Oepen began with a fascinating talk about Art & Mental Illness. He suggested the appearance of art, and also mental illness, occurred about 40,000 years ago, secondary to a mutation in the serotonergic and dopaminergic systems. Art, which comes from an innate drive to create and to form, requires an “audience” to appreciate it. He described the sometimes-remarkable expressions of patients suffering from fronto-temporal dementia, and mentioned that patients with right-sided CVAs are typically happy (but not those whose CVAs are on the left). He told us about the contributions of Picasso, Dali, Jung, and Jean Dubuffet and about a painting by Juan Michael Basquiat that sold for $10 million!

members who spent 100 days together in a module at the Johnson Space Center and about studies of sleep deprivation, isolation, and the elements that make a good team.

The final day began with the Resident Research Award presentation: A White Matter Informed Model of Modulating Connectivity with TMS. Dr. Andrew Murphy told us TMS was approved in ’08 for depression, in ’13 for migraine pain, and in ’17 for OCD. He discussed how different parts of the brain communicate with each other.

The question was whether one could build a model that predicts functional changes from TMS-induced activity changes. They divided the brain into 400 regions and found core and peripheral connections in each area. The prediction model did better when they included structural connectivity, and they found it was more correlated when core-periphery organization was present.

This was followed by Jonathan Hershfield’s lecture about obsessive-compulsive symptoms across diagnoses. He described common obsessions (including mental behaviors like replaying a conversation in one’s mind) and common compulsions like re-reading something.

Compulsions temporarily decrease the sense of being stressed. He listed some other disorders that respond to CBT – like GAD, phobias, and body dysmorphic disorder – then went on to talk about mood disorders, obsessive compulsive personality disorder, and other PD’s. He continued with insights about autism spectrum disorder, ADHD, and PTSD. He closed by talking about patients who may choose to identify themselves as having OCD and advised us to remember to look at “the whole person”.

This was followed by a Neuromodulation Panel with Drs. Michelle Cochran, Ali Farooqui, & Eveleigh Wagner.

Dr Wagner told us that more than 280 million people suffer from depression and that 30% of patients remit and another 30% respond to standard medication treatment.

But under-treatment is very common. ECT leads to remission in 80 – 90% and even severely depressed patients find relief 50 – 60% of the time. However, they are very likely to relapse after 6 months unless they get treated with medication afterwards.

This was followed by the second panel – Drs. Daniel Dahl and Thomas Franklin about the Future of Psychiatry. Half of American psychiatrists are at least 60 years old and 20% of MD’s in the USA plan to retire in the next two years. They talked about Artificial Intelligence, which is capable of constantly teaching itself. People are already developing “relationships” with their A-I systems, and it’s possible to imagine humans not being involved at all in some decision-making in the next few years. (This was among the most thought-provoking of all the presentations!)

Ketamine and s-ketamine were next discussed.

Antidepressant effect could be seen as early as the day of the first treatment. IV ketamine is “not inferior” to outpatient ECT and is better than the nasal s-ketamine. It is not clear if it is necessary to experience dissociation, which is found in 41% of those receiving s-ketamine and even more in those receiving IV or IM ketamine. Ketamine is not approved for depression, though s-ketamine (Spravato) is.

We next heard about vagal nerve stimulation, approved since ’05 for adjunctive long-term treatment of chronic or recurrent depression. There is a 65% higher cumulative response compared to “treatment as usual”. After the surgery, which requires small incisions in the chest and neck, the device is turned on 2 – 4 weeks later. Voice can quaver when the device is on (30 seconds every 5 minutes), though the patient can block that with a magnet.

Mark Wright, MD then told us how “All SADHD Medications Are Not the Same”. He told us how we could use Dexedrine spansules instead of Vyvanse if necessary and about the OROS-concerta system, and about prodrugs that are de-activated, so they are less likely to be abused. He described how patches work to bypass liver metabolism and about how long-acting preparations can be designed in several ways. He mentioned Qelbree, which is a non-stimulant designed as an antidepressant and whose 12 – 14 hour effect can keep adults awake and keep children sleepy.

We next heard more about TMS, which leads to a 50- 60% remission and 80 – 90% response rate in depression. A typical course consists of 36 treatments in 4 – 6 weeks, followed by 1 – 3 weeks of tapering off. The effect may last longer than that of ECT.

Next was an Aerospace Psychiatry Panel, since we had an evening reception scheduled for the Space & Rocket Center. We learned that a mission to Mars – a 1200-day roundtrip - could occur as soon as 2040. There was discussion of the hazards of human spaceflight, including radiation, isolation/confinement, lack of gravity, and hostile/closed environments. We heard from crew

The last talk was given by Mary Helen Davis, MD who volunteered to use Dr. Jon Fanning’s slides when he could not be present. This concerned neuropsychiatric manifestations of Long Covid. The loss of smell is a good indication that the virus is getting into the CNS. Severely

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ill patients experience a high prevalence of clots, and pregnant women frequently miscarry. Among patients who were in the ICU, 46% show cognitive decline at 6month follow-up. We were all impressed by Mary Helen’s courage; it’s not easy giving a talk without any preparation!

Ms. Battin for piling on. They actually defended me and my approach. I pointed out in response that my approach comes from me being in the position of the only one on the panel who actually deals with suicidal people and who sees the profound effect that these laws and practices are having. I also spoke of the ways these arguments influence public health messages about suicide prevention. I referred to the deleterious impact on the actual practice of Medicine by those who are carving out a zone of acceptable, doctor-facilitated suicide. I made no apologies for my display of concern – even a touch of outrage in some of the ways I express my points.

There was a lot of good material in the presentations. I wish I could tell you more about them, but at least you got a taste of what I was able to grasp.

What It Was Like To Testify To Ireland's Parliament About Assisted Suicide By: Mark Komrad, MD

Dr. Jeanne from the Oregon Health Authority, said he was not permitted to give opinions about the rightness or wrongness of these practices. He kept asserting how the Oregon data demonstrate that there have been no problems, no slippery slopes, no concerns about compliance with the law, etc. All of which is incorrect:

I wanted to share my recent experience of testifying before the Irish Parliament Committee on Assisted Dying. They are inviting experts from countries where these practices have been legalized, and I was asked to be an expert witness on the experience in the US.

(https://www.news-medical.net/news/20231004/Reviewof-Oregons-assisted-dying-law-finds-significant-datagaps.aspx) (https://dredf.org/public-policy/assisted-suicide/someoregon-assisted-suicide-abuses-and-complications/)

There were three of us. Tom Jeanne MD, is the chief of the Oregon Health Authority. He was invited to speak about the Oregon experience ( "the Oregon Model") . He is not a practicing clinician, but an administrative epidemiologist. The second was Margaret Battin, a philosopher who argues in favor of assisted suicide and euthanasia. Many consider some of her ideas to be fairly extreme (eg, her infamous thought experiment philosophically supporting the idea of implanting smart bombs in peoples' brains that could be programmed by the person to kill themselves under certain physiological, brain parameters – a suicide advanced directive).

Margaret Battin, and I were in a “debate mode”, with each of us bringing up points to try and undercut the arguments the other made. I kept returning to the viewpoint of a clinician.

The politicians used their allotted time for questions to make their own statements that revealed their viewpoints – in the same way they had framed the questions.

I don’t expect that my participation in this (exhausting) two-hour discussion is going to change the course of Ireland. If I had to guess, I think these practices will eventually be legalized. If they are, I hope Ireland can learn from our mistakes and build a tighter system, so it can avoid taking the road I believe is towards ethical perdition.

I was the third – the only one who is a physician seeing patients. I was clearly there to make the arguments objecting to these laws and practices and pointing out their flaws. As one parliamentarian said, "Dr. Komrad has clearly made up his mind on this." I was trying to argue that the negative ethical and policy consequences outweigh the understandable "good reasons."

Who knows? Perhaps I might have said enough to change one legislator's mind when it comes to the final vote.

The discussion was primarily around Oregon and the Oregon experience, though I tried to keep it more centered on the US experience in general. The parliamentarians were clearly of divided opinions.

Unfortunately, one of them, who's very proeuthanasia (and it turns out is the author of assisted suicide legislation in Ireland) launched a pointed, ad hominem attack on me, deriding some of the ways that I made statements that he called "dramatic, provocative, and not appropriate academic discourse.” (For example, he objected to my use of the term “doctor shopping”.).

Margaret Battin then piled on and said she agreed. Later, two other parliamentarians objected to this attack and were critical of both the MP who had derided me and of

Interview: Paul Nestadt, MD Director, Johns Hopkins Anxiety Disorders Clinic Baltimore, MD September 20, 2023 By: Bruce Hershfield, MD Q: “Please tell us about the work you are doing.”

Dr. N: “Most of my research is in the epidemiology and prevention of suicide. I’m focusing now on the role of firearms, though my most-funded work is actually in

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overdose-caused suicide. I’ve been trying to use psychological autopsy and also other techniques to try to distinguish between intentional overdoses and accidental ones, which is not always so easy to determine. Maryland has had a problem with that determination – we have the highest undetermined rate.”

them, you won’t know if you were right. The Joint Commission calls it a “sentinel event” if a patient commits suicide within 72 hours of being discharged. But, as a Resident, you’re not going to know. We had no quality feedback, which means that a psychiatrist working in the ER for 30 years would not necessarily get any better at making that call.

Q: “You must work with a whole lot of others. I gather you have built many alliances.”

Dr. N.: “All over the place! In academia, of course, but also outside of it. With governmental organizations and other groups. For instance, today, I spoke with “Leading Age”.

They are a support group for people who run residences for the elderly. These are folks who deal with suicides because there are high rates in older populations. They had no mental health training, but they wanted to know how they could identify which residents might be suicidal.

I told them about the “red flag” laws that are now in 21 states and DC. Firearm suicides are even more prevalent in older groups than in younger ones – something like 79% of suicides in those over 75. These people can play a role because they are aware of access to firearms.”

I wanted to know if there was a way I could figure out if I was making the right calls, so I ended up talking to the Medical Examiner. I asked him if I could run a list of the patients I had seen last month past him to see if any of them had ended up in his office because I had made the wrong decision and they had died. So I went in, and we cross-referenced the list. Nobody from our ED had died in that month. The data was in manila envelopes. When I looked at the files of those who did die, I was not confident I would have admitted some of them.

I realized I didn’t really know what a suicided patient looked like. I knew about the ones who had attempted suicide, but most people who die from it have never sought psychiatric care. I opened a folder to see what a true suicide case would have looked like, so that I could better recognize those aspects in my own patients, and the first thing I saw was a full-color picture of the scene. It was pretty graphic – he had used a shotgun. When I learned the details, I thought that if I had seen him in the ER, I don’t think I would have admitted him. I would have made the wrong decision.

Q: “Did you know the President and Vice President are announcing today that they are creating a gun violence prevention center?”

Dr. N: “It sounds like the Biden administration is prioritizing gun violence prevention., which has been a politically hot topic for a long time. It will be interesting to see if they do highlight suicide. Generally, when they talk about gun violence prevention, they are talking about mass shootings or homicides, which are tragic, but the majority of gun deaths in this country are suicides. So, whenever we look at policies that affect gun access, we look at suicides as the outcome to measure.”

I asked if I could look at the other ones. So, I would get all of the data on suicides and overdoses. What really stood out was that the ones who were not getting any care were using guns. Other studies have shown that men – it’s mostly men – are less likely to have been in treatment.

They are just ‘out there in the world’ – until they are not.

But my whole training had been based on the idea that they were in my office – and they were not. So, if I really wanted to decrease suicides, we would need to do it with more public health-oriented interventions, addressing everybody. It‘s the same if you want to decrease the incidence of lung cancer. You are going to have more success with a public health intervention – like making it harder to smoke indoors – than training physicians to convince “at risk” people not to smoke.”

Q: “Suicide is of more interest to psychiatrists than homicide is.”

Dr. N: ”Yes, of course, that’s the ultimate bad outcome in our field. Unfortunately, it’s all too common. It’s the 2 nd leading cause of death for young people, and it remains the 11th leading cause of death, over-all. We still don’t really have any great risk assessments. We do the best we can, but we deal with a high-risk population.”

Q: “How did you get involved with this field?”

Dr. N: “I was initially focused on suicide, not guns. When I was a 3rd year Resident at Hopkins, I was worried. One of our jobs that year is to work in the ER – and one of the most urgent parts of that is assessing whether people need to come in to the hospital or not. We have a limited number of beds and resources, so you have to say if this person who is potentially imminently suicidal is likely to be able to make it to his next outpatient appointment.

Otherwise, he has to come in right now. That decision may be the most important decision a psychiatrist can make in the hospital setting. The ER happens to be one of the least supervised environments for Residents. You make these calls shift after shift, and at the end of the day you don’t know if you were right or not. If you admitted them and they got care, that’s great. If you discharged

Q: “I understand you had a fellowship in epidemiology at Bloomberg. What was that like?”

Dr. N: “That was actually where I developed the statistical tool set that I needed to do this kind of work. It’s called the psychiatric epidemiology training program. It’s a fellowship program that I believe started in the ‘70s. Many of the Hopkins psychiatrists who do research have done it. It’s free-form, rather than rigid. I had a great mentor, Dr. Mojtabai. He is the mentor for more people in public health than anyone else. He is a psychiatrist; he also has a PhD in Psychology. Then he went to Columbia for a residency in Psychiatry. He is a ‘big data’ guy, even though he is a clinician at heart. His real skill set is in doing these complicated analyses of large sets of data. We

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collaborated on my data from the Medical Examiner, and he and I and Pat Triplett looked at what we had.

for this. I was talking with pediatricians there about how they could use this law. One of them, from the Upper Peninsula, said she believes in this law – she understands her patients are at risk when there is a psychiatric crisis, and there is a gun in the house. However, she does not intend to ever file an application for the law to be enforced, because she is only one of two pediatricians in her community. She told me that if she took away someone’s gun, and then deer hunting season came around, it would be all over the social media. She used the word “cancelled’. She also said she might get shot. You don’t want to be this doctor!”

The first thing we noticed had to do with rural suicides.

Rates are higher in rural areas and are climbing faster.

What is it about rural areas? Is there more stigma about mental disorders, fewer psychiatrists, maybe more jobs with economic vulnerability? But it’s also a fact that they have more guns. So, we pushed all the other factors aside and looked at whether it was just the firearms that are driving the predominance of suicide in rural areas. When you look at non-firearm suicides, the rate is lower in rural areas!”

Q: “Politics was supposed to replace violence, wasn’t it?”

Dr. N.:” I told her she was in an unfortunate position, but the best thing she could do – while wanting to protect her patients – was to make it clear this is not a political intervention. It’s a healthcare intervention – the same way you tell kids to wear their helmets when they are riding their bikes. They just need to be stored safely. Maybe the best way to do it is to partner with trusted members of the community. Go to the gun store, and say you are worried about kids getting access to these guns, and maybe we could do a joint event. Maybe we could get funded to give out free gun locks. That way you would be seen as partnering in a mutual effort. Or maybe they would make flyers about a suicide hotline available at the gun shop.

(They are doing this in New Hampshire—what they call the ‘gun shop project’.)

Q: “I sense a feeling of hopelessness about doing anything about the gun problem in the USA because of the political situation. Is there reason to be hopeful?”

Dr. N: “Oh, I am very hopefuI. I think we are going in the right direction. As we just said, President Biden is announcing a highly-funded gun violence prevention center. It’s politically valent, but the general sense among the voters is that they are more and more recognizing the role of gun access in some of these deaths. Not only in mass shootings; it applies across the spectrum. This is being reflected by their elected officials. When I first started this work on gun violence, I was at a suicide prevention conference in Nevada, and I had just had a paper or two on gun violence come out. I was having dinner with some of the gun people, and I said I guessed my next step would be to apply for funding. One of the senior people said he couldn’t advise me to do this because it’s really hard to get funding from the federal government. ‘It’s an uphill battle. You will be fighting for funding in ways that others are not. Keep doing this work, but don’t make it the focus of your funding.

Q: “So do you have any advice for our readers?”

Dr. N.: “ Step 1: don’t be scared to ask your patients if they have access to a firearm. Psychiatrists are used to asking about sex, hallucinations, uncomfortable topics. Ask about guns. It’s medically relevant because having access to a gun increases the risk of suicide by 300%.

Know what your options are about intervening. It might be as simple as asking who could hold the gun during a crisis.

Now, if you talk to those same people, they are advising all their mentees to go into gun work.” The world has changed. This work is suddenly possible.

Q: “A lot of the members of the Southern come from states that have a lot of folks who live in rural areas. What can you say to them?”

Dr. N.: “Folks from rural areas are more likely to be gun owners. It’s complicated, because people who live in rural areas often have their guns for important reasons, or reasons they see as very important. It’s probably best to frame it as figuring out how to handle crisis, so when someone is going through a depressive episode, you want to know if there is a gun in the house. You are not going to run into trouble discussing safe storage of guns.

Tell your patient that maybe this is a good time for your wife to hold the combination to the gun safe or to ask your brother-in-law across town to take them for a while. Inhome storage is good and out of the home storage is even better. Many states, like Maryland, have ‘safe storage maps” – a list of places that have agreed to hold your gun in a crisis. They tend to be shooting ranges, gun stores, pawn shops. Beyond that, if you have a patient you are really worried about, if the person does not want to cooperate, know if your state is one of the 21 that has a ‘red flag’ law. In Maryland it’s called an ‘Extreme Risk Protection Order (ERPO)’.”

The NRA started as an organization dedicated to responsible gun ownership. They encouraged safe storage. It’s when you have to be more paternalistic that you run into problems. For instance, I was in Lansing, Michigan, last week because their ‘red flag’ law was coming on-line in the next few months. Their law – which allows for people who are worried about someone to remove the firearm from their home and also to keep them temporarily – is one of the few that allows clinicians to file

Q: “Would you encourage our readers to ask that their states also pass laws like that?”

Dr. N.: “Yes, and there has been a big push from the Biden administration to fund states to pass them if they don’t have them already. Some states have them ‘in the pipeline’. It’s a good idea to advocate for a law like that.

For every 11 guns seized by a ‘red flag’ law, one suicide is prevented.”

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Ageism & Implied Bias By: Jenny Boyer, MD APA Area V Trustee

statement, and training materials (such as CME, podcast, resource documents or other educational materials) specifically addressing Ageism. It passed. Now we can see what we can do together to improve how we handle this problem.

Having been in multiple “Diversity, Equity and Inclusion (DEI)” meetings in professional organizations, I would like to share that ageism is not as high a priority as it might be. Ageism is not the same as racism, but it is similar in implicit bias and inequity. Older members are not equally valued; middle-aged people are the most valued, followed by the young. Younger people also have bias against them, based on age – much like older people. There are also intersections with other social determinants. For example, age and sex interact in that older women are less valued than older men. Being told that I look good for my age – after serving for years in an organization – does not make me feel like I was as valued for my contributions as I had been when I was younger.

However, I blame no one, as I think it is unconscious or implicit bias.

Artificial Intelligence [AI] in Psychiatry By: Harold M. Ginzburg, M.D., J.D., M.P.H. Artificial intelligence, AI, is a computergenerated integration of available data into logical sentences and paragraphs. It is a predictive model based on its source material, which is not provided, as references, in its output. This can be problematic. On June 23, 2023, the Associated Press wire service published the results of legal proceedings that occurred in the court of United States District (Federal) Judge P. Kevin Castel. The Judge fined two lawyers and a law firm $5,000 in “an unprecedented instance in which ChatGPT was blamed for their submission of fictitious legal research in an aviation “injury claim.” The Judge stated the lawyers “acted in bad faith” and concluded “technological advances are commonplace, and there is nothing inherently improper about using a reliable artificial intelligence tool for assistance. . . But existing rules impose a gatekeeping role on attorneys to ensure the accuracy of their filings.” If this were a medical malpractice case, and the actions of the doctor were reported to be based on fictitious medical information provided by GPT, would the doctor only have been fined $5,000 and retained a medical license?

I have been asked if I am still sexually active and if I need to have my groceries carried. But, most importantly, why I don’t retire and if I know that I am aging. I AM TOLD I AM NOT TO TELL MY AGE IF I WANT TO BE ELECTED OR RESPECTED. It reminds me of when I was told by a professor that I needed to change my name, as it was not formal enough. Or that “Jenny” was for people of color. I was told I needed to work on my Southern accent, as it was interpreted as being less educated and an indication I was prejudiced against people of color. I was told I probably had been accepted into graduate school because of my looks. I am no longer spontaneously asked what I think is the future of the profession. I must be more assertive in order to be heard.

What has this legal case in common with using GPT in medicine? As a forensic psychiatrist, I was preparing a lecture to be given to psychiatric residents, and I could not recall the dates of a legal case in Louisiana, in which limited immunity for medical, including psychiatric, experts was established by case law. GPT provided a response, which I immediately recognized as being grossly inaccurate. It was a case I was involved in and thus I knew the fact pattern. I have used that search product to demonstrate to the psychiatric residents the hazards/limitations of GPT programs.

I am aware that we must have younger people participate.

I am also aware that it is good to work with people who have experience and historical perspective. However, though older people may have trouble recalling a name for a moment, we can have better judgment – sometimes referred to as “institutional memory” – than those who have not had such full professional and life experiences.

We can provide the diverse perspective that comes from age. Other generations can provide energy and innovation and risk-taking, which makes the mix stronger.

Perhaps the concept of ageism is sinking in. I recently applied for three jobs and got all three – and I am a senior.

I did not encounter any slights in the job interviews.

There are other more subtle hazards to using GPT systems. The limitation of GPT programs is that a reference from the New England Journal of Medicine could be given the same ‘weight’ as a ‘Bot’ entry. That is, the relative merit of ‘facts’ provided by GPT programs cannot be independently verified by the reader. Also, GPT, at least the public access versions, are designed to appear to a wide and even international audience. This audience-directed response limits the specificity of the AIgenerated responses.

I am sure that the implicit bias (or micro-aggression, as it is called in racism) is not intentional. People do not realize any harm in what they are saying or doing. But they harm me and older patients that need us to represent them.

So, I authored a paper in the November Assembly, as the Delegate from the Senior Psychiatrists. It resolves that the APA, via the appropriate Councils, develop a position

Some examples of GPT responses to psychiatric medication questions are provided below:

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advisory, but the final clinical decision and the effects of potential patient outcomes still remain with the clinician.

Does GPT offer more than a perusal of a standard textbook or review article? New technologies do not necessarily provide better answers, but they may provide more information in a different format. The limitation of GPT is that the source(s) of the information are not available for an independent review and assessment.

Educated, referenced, medical algorithms still provide the best basis for addressing the patient’s problems.

The medical question posed was: What is the dose of sertraline for a 135-pound woman?

The response was: “I’m not a doctor, but I can provide some general information about sertraline dosing. Please note that it’s important to consult with a qualified healthcare profession or a psychiatrist for personalized medical advice.” The response continues, “The appropriate dose of sertraline can vary depending on several factors, such as specific condition being treated, individual response to the medication, and other medical considerations.” The response concludes: “If you have specific concerns about sertraline dosing for 135-pound woman, I strongly recommend consulting with a doctor or psychiatrist who can evaluate her individual needs and provide appropriate guidance.”

The Problem of A-I Solving Issues in the Care of Demented Patients By: Harold Ginzburg, M.D., J.D., M.P.H. Clinical algorithms are a fundamental backbone of clinical medicine, including psychiatry. We can diagnose some conditions such as Down’s syndrome or fetal alcohol syndrome by observation. Then, we take a comprehensive medical and psychiatric history and order appropriate laboratory studies to confirm the diagnosis.

Thus, GPT suggests you consult with “a doctor or psychiatrist,” suggesting that psychiatrists may not be doctors, a subtlety that may not be lost on the readers of this response. Also, GPT provides no medical conclusions – only vague information that would be known to a senior medical student. A package insert might be of more value, as the response fails to mention the possibility of adverse or side effects or the potential lethality of giving a large prescription of this medication to a seriously depressed and potentially suicidal patient.

The addition of artificial intelligence, based on breakthroughs in natural language processing and large language models, may increase clinical acuity – but only if the correct lines of inquiry are entered into the search engine. However, rendering a diagnosis is not sufficient to alleviate a patient’s distress. The planning and implementing of social interventions for chronically ill patients cannot be achieved by developing and then implementing A-I generated responses alone.

The medical question posed was: “What happens when a pregnant woman takes topiramate?” GPT identifies topiramate as a teratogenic medication by indicating that it “has been associated with an increased risk of certain birth defects” and the “risk appears to be dosedependent.”

A recent article on palliative care of patients with dementia, indicates that “6.7 million people over 65 years of age, in the United States are living with dementia, and they are cared for, in part, by 11 million unpaid caregivers.” The article’s data suggest that approximately 2% of this country’s population suffers from dementia and an additional 3.3% are their unpaid caregivers. This is a significant social and economic burden.

The response concludes, “It’s important to have open and honest discussions with healthcare professionals regarding the use of topiramate or other medications during pregnancy to ensure the best possible outcome by both mother and baby.” The response is sage, and it does not state that healthcare professionals should have open and honest discussions with the patients. The audience thus seems to be the patient, not the health care provider.

A most honest response was generated in response to the following more specific question:

The newer medications, anti-amyloid and emerging antitau therapies, focus attention on early screening and diagnosis. Chronic care will still eventually be required.

The longer the clinical course, the longer the anticipated dysfunction. The longer course of the decline in activities of daily living, and delay to death, will require more supportive care. Most of this, if tradition is honored, will not be provided by medical and medical ancillary professionals. More geriatricians, in more diverse and dispersed locations, and more interdisciplinary care teams, are needed, since primary care providers lack the time to provide in-depth treatment during 15-minute appointments. However, the reality is fewer geriatric specialists are being trained and most remain in urban settings. Because interdisciplinary teams are less costeffective there may be a financial disincentive for institutions to create and fund them.

The question posed: “A patient reports difficulties in concentrating and recalling information that was read. He is easily distracted. He is 74 and was exposed to Agent Orange in Vietnam. His gait is abnormal.” GPT provided the following answer: “Based on the information provided, there are several possible factors that could contribute to the patient's symptoms. It's important to note that as an AI language model, I cannot diagnose medical conditions, but I can provide some general information and possibilities for further evaluation.” This remains a significant caveat in the future use of AI. These examples provide reasonable, but limited, information. AI-generated responses are informative and

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While A-I is touted as placing people, patients, communities, and clinicians in its “cross hairs” – at the center of supporting health care, including geriatric health care – the reality is that there is a paradoxical decline in the number of geriatricians. The number of boardcertified geriatricians has declined from 10,270 in 2000 to 7412 in 2022.

and its Foundation. Intriguingly, the position was described as “CEO and Medical Director.” (If the title was worded as “Medical Director – CEO” it would be clear they were not looking for a CEO with a major in Finance or Marketing with no background in Medicine or Psychiatry.)

This is indicative of a trend that may turn out to be ominous for our profession. The State of Maryland recently passed a law to recognize certified nurse practitioners as medical directors in mental health institutions. There was also news about a nurse practitioner in Chicago firing 9 psychiatrists after she was appointed to be a medical director (immediately replacing them with nurse practitioners). These developments have raised some alarm about the future of psychiatrists in the work field.

There are two obvious reasons for this. Older physicians, who became certified early on, have retired, and those who initially were board-certified have opted out of recertifying. In the 2022 national geriatrics match only 177 of 411 available positions were filled. It is reported that this was the lowest percentage of all fellowships across 71 medical specialties. Thus, while we have better machine-based learning to assist health care providers, we have fewer skilled health care professionals to address the specific needs of the elderly in a country whose population continues to age.

The Assembly of the APA acted and has passed an Action Paper directing the BOT to require the “CEO and Medical Director” to be a practicing psychiatrist, certified by the American Board of Psychiatry and Neurology. All the candidates selected by the firm and presented to the BOT have turned out to be Board-Certified Psychiatrists.

A-I now focuses on algorithms for clinical interventions. It does not focus on the human elements of Medicine, nor can it produce human health care professionals. It does not appear, at least at present, to be focused on improving quality of life for patients with dementia and those who engage in their treatment – their family, and caregivers. It remains an unemotional tool to improve quality of care, but not necessarily the quality of life.

But it is still unclear if the organization has resolved all differences of opinion in this domain. Lack of clarity is likely to lead to consternation and future confusion.

Physician Attitudes Towards Mental Health & Suicide

Let’s Be Clear about Medical Directors By: Shree Vinekar, MD The role of Medical Director can be confusing, with varying responsibilities and expectations. Clearer understanding would ensure that medical directors can effectively lead and support their teams and would avoid confusion and conflict within organizations.

We need clear job descriptions and expectations for medical directors, who themselves should strive to communicate about their roles and responsibilities.

By: Tara Tamton, D.O., Audrey Summers, M.D., & Ali A. Farooqui, M.D. University of Louisville Suicide is a leading cause of death in the United States, with 48,183 Americans dying from it in 2021. Suicide risk is impacted by age, sex, race/ethnicity, socioeconomic status, and profession – with physicians having an increased risk compared to the general population.

Approximately 300, or 30 out of every 100,000 physicians, die by suicide every year. Suicide risk among female physicians is greater than for male physicians. The data suggest that risk is highest among anesthesiologists, psychiatrists, general practitioners, and general surgeons. Suicide is the second leading cause of death among people aged 10-34, which is the age range when most physicians complete residency training. In addition, there is a 15.8% increase in depressive symptoms during the first year of residency training.

The APA went through an interesting dialogue among its leadership after its current medical director, Dr. Saul Levin, announced he would retire in June 2024 and was moving on to become the Secretary-Treasurer of the World Psychiatric Association. A private firm was employed by the Board of Trustees of APA to recommend prospective candidates. The instructions given to this firm did not clearly state that the director should be a psychiatrist, certified by the ABPN. Dr. Levin, an IMG who was trained in the US, is not board-certified by ABPN. The Board of Trustees (BOT) sent a letter, co-signed by the current President of APA, that “every effort will be made to appoint a psychiatrist for this position”, but it was clearly hinted that the CEO could be selected based on other capabilities, such as the capacity to manage a large budget and to direct the investments of the Association

Interestingly, despite objective and anecdotal evidence that physicians have a higher risk of suicide than the general population, CDC data analyzing suicide trends did not include doctors. This study listed occupational groups with significantly higher suicide rates, especially among female civilian working persons aged 16 – 64

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years. RNs were among the groups with a high suicide rate, while healthcare practitioners in general had a slightly lower rate than them. The CDC study did not clarify which occupations fit into that category.

being a good father. Similarly, as a mother and a physician, I have the right to strive for my own career advancements.

The sacrifices I have made professionally and personally seem undervalued; my competency and dedication are underestimated in comparison to my husband’s. I leave the hospital every day around 4 p.m. to 5 p.m. to pick up my son from school. My husband doesn't leave work until 7 p.m. or 8 p.m. I cook, clean, help my son with his homework and get him ready for bed, trying to squeeze in some "me time" before my husband arrives home. The next morning, I wake up early to help my son get ready and drop him off at school.

Unfortunately, at the end of the day, I – the “physician mom” – will be the parent who is considered to work less.

All because I am not making all the effort during work hours, no matter how hard I am multi-tasking.

Given this paucity of data, we surveyed physicians and other healthcare professionals in Kentucky to investigate their suicide risk and mental health burden.

The survey had 89 respondents, with 69 of them being physicians specializing in Psychiatry. Two-fifths of the respondents had experienced a depressive episode in the last 5 years, and 19% reported a history of contemplating suicide. Incidence was higher among females (n = 24).

17% of subjects admitted to experiencing a substance use disorder at some point, with greater incidence among males (n = 11). Unfortunately, 32.6% of all participants stated that they would avoid seeking treatment for mental health or substance use due to perceived stigma. 20.7% stated that they would doubt the clinical judgment of a provider who sought treatment for mental health or substance use, and 27.9% of respondents stated that they would doubt the clinical judgment of a provider who contemplated or attempted suicide.

I have to think: what if I get pregnant? If I match with a residency program this year, should I postpone the pregnancy? If I do not match this year, but I’ve already postponed the pregnancy, the same issue would be in my mind for the next match season. This dilemma is common for female physicians who are starting a new position as an attending faculty or medical director.

Work-life balance, administrative responsibilities, moral injury, burnout, years of training, maladaptive behaviors have all been implicated in various studies. Physician wellbeing should be prioritized, but it is subject to various barriers. Our study indicates that stigma remains a significant deterrent to physicians struggling with psychiatric and substance use disorders.

Physician/mothers face a unique set of challenges in balancing the demands of a medical career with the responsibilities of child care. Female doctors in general encounter additional hurdles due to gender stereotypes, harassment, and biases, like being passed over for promotions and/or regarded as less competent. These challenges can cause anxiety, depression, and personal conflicts, negatively impacting personal and professional lives. Stereotypes may perpetuate the notion that physician-mothers are less capable of effectively managing their professional responsibilities.

Consequently, these biases can result in reduced opportunities for leadership roles, exclusion from important projects or committees, and challenges in accessing mentorship opportunities, which are vital for career development.

Changing the terminology around psychiatric illness is likely to help to reduce stigma. For example, a cultural shift toward understanding mental illnesses as a set of diagnosable disorders requiring treatment and not a shortcoming that requires “help” would likely empower healthcare professionals to seek appropriate care.

Although access to qualified providers to deliver evidence-based psychiatric care remains a barrier to improving the over-all mental health, targeting the attitude of the profession may help a great deal. Attitudes and culture likely vary among specialties, areas of practice (private vs community vs academic), and various other demographic factors, which makes addressing stigma a moving target.

The creation, nurturing, protection, and development of a new life should be celebrated and supported within the medical profession. Mentorship programs that specifically cater to the needs of physician/mothers can help counteract biases and provide guidance and support.

Additionally, implementing flexible work structures can help alleviate the challenges they face. Part-time work arrangements, remote meetings, and flexible scheduling have been shown to help during the COVID-19 pandemic.

For hands-on work, designated workdays and on-site childcare facilities can be arranged. Creating times for school-aged children in their parents' facilities – like afterschool hours – can contribute to the well-being of the next generation and allow parents to interact with their families during break times. These measures can support parenting attachment, reduce stress, and enhance productivity.

The Challenges Facing Physician Mothers By: Sumeyra Baskoy, MD. – Observer, University of Miami & Steven Lippmann, MD, Emeritus Professor, University of Louisville I (SB) am a 35-year-old female physician, aspiring to regain my medical career and to realize my professional goals. I’m busy, with a 6-year-old son and a husband who is a surgical Fellow. Yes, it is my spouse’s right to pursue his desired specialty and manage its demands, while also

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This requires a collective effort from employers, colleagues, and spouses. Employers can establish policies that promote work-life balance, offer childcare facilities or subsidies, and provide mentorship opportunities. Colleagues can help by challenging biases, advocating for equal opportunities, and offering support.

Spouses and partners can share household and parenting responsibilities, allowing female physicianparents to pursue their careers.

isolated during the pandemic, witnessing his death created more depressed, and their emotions became overwhelming. In another case, to avoid the neighbors talking about them, a family kept their son’s COVID-19 symptoms secret, utilizing home-treatment remedies. A week later, he expired due to hypoxia. If they would have had their child admitted into a hospital on time, he might have remained alive. Events like this motivated me to write this article, to create more public awareness.

The challenges that physician families face have long interested me (SL). My family immigrated in the late 1930s; Education and healthcare were powerful, long traditions. My father was an ophthalmologist, and my mother was a nurse in their practice. As a teenager, when my dad had night-time emergencies, like corneal abrasions, I would assist him. During college, I told my mom that I had decided to “go” premed. She was unsurprised. At medical school interviews, when asked why I wanted to be a doctor, I said I could not think of any other profession. My sister and her husband are neurologists.

The frequency of suicide escalated over the last two decades, even before COVID-19 emerged. It was among the top 10 causes of mortality in the U.S.A., and the second most common cause of death in people aged 1014 and 25-34 years. This pandemic increased the incidence of suicide, particularly among those infected by coronaviruses. During 2021, suspected suicide attempts increased by nearly 51% and 4% among girls and boys of 12–17 years of age, respectively. Among 7,002 research subjects, over 6% reported experiencing thoughts about suicide during this pandemic.

Sociodemographically, suicidal ideas were more commonly reported among those who were over age 65, unmarried, of unconventional gender preferences, and by those who experienced a pre-existing mental health condition. Isolation, loss of loved ones, loneliness, unemployment, economic or housing stressors, school closures, substance abuse, and coronavirus illness were predictors of high-risk.

When my two daughters were teenagers, they indicated they were interested in Medicine. Ultimately, one became a physician and the other one, a nurse. Currently, I have one niece practicing healthcare law, and another one who is a family medical Resident, plus at least one cousin who is a practicing physician.

We can all – mothers and fathers, husbands and wives, and our children – help foster a more equitable and inclusive healthcare system that values the contributions of all physician-parents in creating and nurturing new life.

The 1918-1920 flu and the 2003 SARS epidemics precipitated increased suicide rates; prominent reasons included fear of infection, social isolation, and diminished personal support. This pattern also re-emerged during COVID-19 times. Stay-at-home measures and physical distancing added financial strain and reduced access to socialization, education, jobs, housing, and medical care.

Quarantine and lockdown orders often resulted in harmful impacts to emotional health.

Suicide Upsurges Surrounding The COVID-19 Pandemic By: Kshetra Challapalli, M.D., University of Mississippi Medical Centre, Jackson, MS and Steven Lippmann, M.D., Emeritus Professor, University of Louisville

Suicide-prevention hotlines were and are still busy; our national, new suicide prevention telephone number is 988. However, emergency medical contacts for suicidal crises and/or behaviors surprisingly decreased in early 2020; perhaps this is explained because some people avoided healthcare attention due to fear of contagion.

Anxiety about COVID-19, though genuine, is often exaggerated. Some people, for example, utilized false interventions like ingesting bleach or ineffective medicinals, intending to keep safe from the virus. There reportedly was a COVID-19 patient, who committed suicide to protect his family from exposure to the coronavirus. One whole family jointly committed suicide apparently after being isolated and stigmatized following their father’s death from a coronavirus infection.

Suicide was a common cause of death before COVID-19.

There are many reasons why people may contemplate ending their own lives, like romantic disappointments, failed relationships, unemployment, financial issues, emotional crises, and/or mental illnesses. With the coronavirus pandemic, anxiety joined the list. If such an emotion can result in death of a person, then it should be vigorously addressed. Even as the pandemic attenuated, anxiety persisted, though to a lesser degree. Unreliable information about coronavirus diseases facilitated people remaining anxious. Social stigma about COVID-19 also exacerbated tension levels.

Loneliness often causes emotional stress and substance abuse issues; this can precipitate depression, contemplating suicide, and anxiety issues. It is also linked to a wide variety of physical ailments. Our US Surgeon

I (KC) knew of a family in which the wife and kids committed suicide after having lost their bread winner to COVID-19. They, and most everyone, were already

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General, Dr. Vivek Murthy, publicly endorsed this concern on May 23, 2023. Quarantining has yielded similar adversities during previous pandemics. Chemical dependence rates increase when people feel troubled, lonesome, and are not productively occupied.

Unemployment exacerbates self-medication tendencies; overdoses occur more often in such cases. Enhancing socialization is becoming a new national concern focus.

long relied on direct one-to-one personal contact for social well-being. Let us apply what we learned during COVID19 to our future. Good luck.

Learning Empathy And Professional Cooperation While on Psychiatry By: Azzam Malkawi, B.A., 3rd year medical student & Mustafa Mohamed, B.S., 3rd year medical student University of Louisville School of Medicine

The SARS epidemic isolations also escalated stress and post-traumatic stress disorders, even long after the epidemic had subsided. Survivors of COVID-19 illnesses are also at risk for isolation, occupational, housing, and financial insecurity, and many chronic psychiatric and physical morbidities like pain, strokes, and seizures, etc.

Sleep disturbances are another risk factor, often induced by fear of contagion. Sleep quality and self-esteem are negatively affected by isolation and may escalate the risk for anxiety, depression, suicide, and somatic pathologies, especially those due to vascular and metabolic etiologies.

As third-year medical students, we (AM & MM) rotated through various clinical specialties; Psychiatry’s clerkship was no exception. We gained understanding about the challenges and rewards of Psychiatry and hope to inspire other medical students to explore this as a career option.

Psychiatrists encourage people to take better care of themselves as an initial intervention. Everyone should be taught the value of vaccines, masking, and about keeping “physical” distance, rather than “social” distance. It is helpful to stress the importance of maintaining communication and socialization, while still endorsing guidelines of physical protection (… much easier said than done …).

To begin, I (AM) encountered a patient with a self-inflicted gunshot wound – “Ricky". Our first meeting was memorable: he appeared to be comfortably in bed with a bandage covering his face and eye.

He had shot himself in the eye during a difficult divorce / custody battle. He had resorted to drinking alcohol and that had worsened his emotional status. He claimed that his life previously was “perfect” and that he was "shocked" by his actions. His wife said he was intoxicated that night and shot himself impulsively or maybe by accident. His blood alcohol level was at 250 mg/ml at the time of admission. He was surprisingly calm and resilient, saying he would be “okay” and was optimistic about his future. A supportive social network made the prognosis feel safer.

I assessed Ricky for many days and got to know his family. This experience also highlighted the importance of communication and collaboration between healthcare workers. Ricky required extensive interventions from teams of physicians, nurses, and therapists, each with their specific area of expertise. Ricky’s condition taught me much about myself. I had lots to learn about emotions and their impact on people's lives.

Telepsychiatry expanded access to mental and other health services, especially during the high infection risk periods. Home-delivery of medications and/or meals frequently provides additional comfort. Nevertheless, maintaining as much interpersonal communication and direct contact as possible is advised; socialization improves health, diminishes stress, and curbs substance abuse. Online social media sites about suicide awareness can diminish suicidal thoughts, share feelings, and with anonymity, offer support to one another during a crisis.

A return to one-to-one, in-person psychiatric care as contagion abates should hopefully lessen some of these concerns. Telemedicine is a great “stop-gap” measure that has greatly augmented access to care. Lots of people document how convenient and available telepsychiatry has become. It can aptly provide clinical needs in selected cases, especially for psychiatric consultations, as in rural and/or in other underserved circumstances. Telehealth care is also more easily and comfortably accessed, with less time constraints, and greater flexibility to appointments. However, telepsychiatry does not replace the personalized, positive impact of face-to-face clinical discussion.

During my psychiatry rotation, I (MM) observed how productive interactions between medical professionals and patients can impact outcomes. I encountered "Pam", who had many years of living a happy life with her partner until he died. Her situation deteriorated; she lost all they had planned together, her truck, and her home. Because they had never married, her partner's children received all their assets. In response, she began using alcohol and crack-cocaine. Subsequently, she developed a protracted depression that resulted in the psychiatric hospitalization.

Previously, she had been personally resilient, but now her self-confidence had declined. After evaluating Pam, I realized that anyone could become a person in need of mental health help.

There is a major advantage of person-to-person interaction in the patient-to-doctor relationship. Eyecontact is part of that connection. Greater intimacy augments how well the physician can clinically assess patients and sometimes also improves after-theappointment patient trust and compliance. Humans have

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Growing up in a Sudanese household where – for boys – emotions and depression were considered feminine traits, I wondered how I would have coped with such a struggle.

Currently, beyond making me a better doctor, I hope this experience might even improve my ability to cope with adversity.

acting troupe with members of Kentucky’s Buddy House, a center assisting people with Downs Syndrome.

Some notable Miss Kentucky initiatives from fellow University of Louisville students also centered on mental healthcare. My medical school classmate, Ashley ShaeBenton, advocated for mental health care for victims of gun violence with her platform Heal with H.E.A.R.T (Health Education, Advocacy, and Resilience in Trauma).

Tayler Plunkett, a graduate student studying speechlanguage-pathology, was passionate about educating Kentuckians about neuropsychiatric disorders like ADHD, autism, and OCD through her initiative titled Neurodiversity: No Brain is the Same. Taylor Henry, campaigned for suicide prevention and better mental health supports.

Psychiatrically interacting with Ricky and Pam was for us a challenging-but-learning experience. We better understand the importance of empathy and collaboration in providing medical and substance abuse interventions.

As future physicians, we will strive to approach patients with understanding, to work collaboratively with other professionals, and prioritize our own well-being so we can provide good patient care.

Many contenders were pushing for specific social programs and/or supporting at-risk populations. Lillian Mosely suggested combatting social isolation by encouraging people to participate in hobbies with others with her proposal “Igniting a Spark for personal passions.”

Olivia Andrews championed using music therapy to alleviate mental health issues with her platform “The Miracle of Music.” Chapel Tinius and Molly Sullivan, recent graduates of Belmont University and the University of Kentucky, respectively, also want to assist specific communities at risk for mental health issues. Chapel’s “Operation Gratitude” was centered on serving US veterans, while Molly’s “Sunshine for Kentucky” resolved to help Kentucky Farmers.

Mental Health and Miss Kentucky By: Ankita Nair, B.S., Medical Student University of Louisville School of Medicine This past summer, just days after taking the STEP 1 exam, I went to Bowling Green to compete in the 2023 Miss Kentucky Pageant. Already Miss University of Louisville, I traded my hospital attire for a glamorous wardrobe of evening gowns, business suits, and formal dresses. There were over 15 events, and I competed against 25 outstanding women. On stage, I advocated for preventative health, played Tchaikovsky on piano, and performed an intricately choreographed dance number.

This year’s competition had the highest number of interventions addressing mental health, indicating that it has become enough of a crisis that people outside of healthcare feel compelled to promote productive actions.

Medical students rarely participate in pageants, but I chose to compete because of the opportunity to perform community service. The Miss Kentucky Competition is unique amongst some pageants because it identifies as an academic scholarship contest that rewards the winner with an opportunity to work for the state and perform a year of public service. Even more special, candidates get to choose the specific social issue they wish to address – campaigning for their platform and demonstrating their past community involvement. As a medical student, I ran on a platform I called “Let’s Live Kentucky.” I suggested that educating Kentuckians about prevalent diseases and sharing healthy lifestyle practices would help improve public health. I stressed how mental health deserved to be a part of that.

Pageants understandably carry the perception of being superficial because of competition events like modeling gowns and fitness attire. However, my experience demonstrates that these competitions can be a platform for candidates to express desire for meaningful social change. Every woman there had spent months volunteering in their local communities working diligently towards a laudable cause.

The Miss University of Louisville title encouraged me to look beyond my duties as a medical student and to engage more with my community. Long after I pass on my title next spring, I hope to continue my work promoting preventative health awareness through “Let’s Live Kentucky.”

To my surprise, several other candidates were also bringing attention to this issue. Mallory Hudson, the newly crowned Miss Kentucky, won in part because of her work helping individuals with Downs Syndrome and sensory processing disorders. Her project, “Inclusive Stages,” advocates for greater social inclusion of individuals with disabilities. She hopes to provide theatrical and artistic opportunities to people with special needs. While sharing a dressing room with Mallory, I learned about how she impressively started an inclusive

A New Era of Authentic Social Media By: Ankita Nair, Medical Student, University of Louisville School of Medicine Image-based social media platforms – like Facebook, Instagram, and Pinterest – have the reputation of curating inauthentic content. The

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use of Photoshop, filters, and strategic posing has made it increasingly difficult to discern real life from manufactured content.

Fit-Twin & AI: Can It Enhance Psychiatric Care?

By: Muhammad Sulaiman, Ph.D. – research fellow & Amal Mumtaz, M.D. – resident physician & Steven Lippmann, M.D. - Emeritus Professor, University of Louisville School of Medicine

In the last three years, companies have responded by creating platforms like BeReal and Dispo that encourage more genuine interactions. Both programs are used mostly by young adults and adolescents; for example, 90% of Dispo users are under age 24.

Digital healthcare involves technologies, such as mobile apps and wearable devices. The shift to depending on it in healthcare delivery suggests that future medical care will be more connected, predictive, and proactive; it might also be more personalized, giving every user a unique status.

BeReal, an app created in 2019, has been downloaded over 67 million times. Its premise is that all users receive a notification at a random time each day to submit a post called a “BeReal” within a two-minute window. A BeReal is a photo taken with both the front and back phone camera lenses on, so viewers see both a “selfie” of the individuals and their current surroundings. One can only post a single image a day and there are no filters, editing tools, or publicized follower counts. Users can try several times to take a photo, but the app lets others know the number of tries. The unknown posting time and the twominute window encourage authenticity because users must react spontaneously. Otherwise, the app notifies exactly how late a user is, and also if they post after the window closes. Currently, it is funded by investors and does not utilize advertisements. BeReal’s namesake comes from the app’s reported intention for people to be “more real” or authentic and a pun of the photographic term “B-reel,” used to describe excess footage.

Wearable devices, such as Fitbit, Apple Watch, and Garmin are popular for tracking physical activity, sleep patterns, heart rate, and other biometric data. The collection and analyzed real-time data might provide insights into someone’s emotional status. This availability affords new opportunities for psychiatric practice.

One such prospect is the use of digital twins: a concept that has been applied in engineering and manufacturing.

A Fit-twin is a digital twin that offer a potential means to assist medical professionals to make more informed decisions regarding a patient's clinical status and potential interventions. It could enhance monitoring patients with depression or anxiety.

Dispo was also created in 2019, and it too limits users’ photo abilities. It derives its name from “disposable” and mimics the experience of using a disposable camera.

People can take an unlimited number of photos, but they cannot see the images immediately. Instead, they must wait until 9 a.m. the next day for the images to “develop”.

Photos can be posted, and other people can comment, but there are no editing tools or captions allowed. A July 2022, video released by Dispo’s CEO, Daniel Liss, revealed that the app was downloaded over eight million times. It has minimal advertising. Liss says that the app encourages authenticity by prioritizing “fun and mental health”. The app makes it difficult for influencers to profit from the platform by not allowing captions or using an algorithm to curate content.

It documents physiological parameters with real-time data from wearables. For example, depression often correlates with changes in sleep patterns, decreased physical activity, and less heart rate variability. This information may help healthcare professionals to offer earlier, optimal interventions. Anxious patients might experience tachycardia or tachypnea; the device could alert them and help their doctors manage their care.

Intranasal Esketamine Spray as Emergency Suicide Prevention By: Rana Anwar, M.D. & Steven Lippmann, M.D.

BeReal and Dispo are changing social media by avoiding features like algorithms, advertisements, image manipulation, and a constantly refreshing “feed”. Both companies place stipulations on users in exchange for authenticity. These new platforms imply that they improve wellbeing because they only require people to check their apps once-a-day, encourage the sharing of unfiltered, spontaneous images, limit advertising, and make it difficult for social media “influencers” to profit from them.

There are many interesting reports about the potential of esketamine to rapidly diminish suicidal preoccupations in patients with serious, and even treatment-resistant, depression. While a research physician at the University of Louisville, I (AR) became concerned about the high rates of suicide, particularly among the young. I learned that neither ketamine nor esketamine is currently utilized to curb suicidal thoughts in our ER.

It will be interesting to know the real long-term effects of them on mental health and/or wellness.

For me (SL) ketamine prominently came to mind well over one decade ago, while my daughter was in residency.

While there, she participated in research about its suicide preventive action in the Emergency Medicine

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Department. Ketamine was actively prescribed to suicidal patients in an investigatory study phase. While ketamine had previously been used within our psychiatry services, that is no longer so, and it is not currently available to our emergency psychiatry unit. Esketamine is similarly not prescribed within this system, even though it is easily administered intranasally and is potentially life-saving.

Hopefully, this situation can soon be remediated. This is a good time to modernize our therapeutic options and to improve education about modern interventional methodologies for our trainees.

Intranasal esketamine administration at 28 mg, 56 mg, and 84 mg doses has been established as being safe, and with no significant clinical concerns. A clear dose-toresponse relationship has been documented in terms of emotional improvement one week after pharmacotherapy, with lower doses resulting in a shorter duration of benefit. Larger doses of ESK are required to reverse suicidal thinking in some treatment-resistant and/or chronically depressed patients. In addition to the short-term mood-elevating effectiveness, the attenuation in suicidal thinking may persist for up to a month.

Suicide is the second leading cause of death for people in their twenties. Each year, over 500,000 patients present to Emergency Medicine Departments with a chief complaint of either suicidal ideation (SI) and/or behaviors.

Up to 60% of people with major depressions experience SI, and about 20% attempt suicide. Approximately 50% of those subjects do not respond adequately to an initial selection of a conventional antidepressant drug. Up to 30% of them fail to improve even after two or more antidepressant medication trials – experiencing so-called, “treatment-resistant depression.”

Repeated esketamine treatments might stabilize many patients clinically and even prevent relapse. However, protracted intranasal ESK efficacy is not consistently observed. Clinical observation over time should help clarify our knowledge. Hopefully, we can soon make better use of it for emergency interventions.

What About Huntington’s Disease?

By Rana Anwar, M.D. - Clinical Research Coordinator & Steven Lippmann, M.D. - Emeritus Professor, University of Louisville School of Medicine

Antidepressants often require several weeks to reach optimal efficacy. Consequently, they are suboptimal for some acute suicidal crises. We need a quick-onset treatment that is effective and safe.

I (RA) am writing this article about Huntington's Disease because of my interest in how genetic testing significantly impacts family planning decisions. I have concerns about being able to correctly make the diagnosis or rule out neuropsychiatric and/or other differential diagnoses. The same applies to designing an appropriate therapeutic regimen. The choices patients make regarding this condition can alter their lives and those of their families.

Also, intriguing are the challenges of identifying Huntington's Disease promptly – and the value of confirming the diagnosis – in people of childbearing age.

Ketamine’s antidepressant and anti-suicidal effects have been established. An N-methyl D-aspartate (NMDA) receptor antagonist that modulates glutaminergic transmission, it can induce meaningful relief from suicidal ideation in as early as 40 minutes. It has been available for decades in anesthesia, producing short periods of sedation or analgesia with amnestic properties.

There are also clinical and statistically significant reductions in suicidal thoughts at 24 hours documented after 0.5 mg/kg ketamine infusions. Efficacy remained for attenuating SI in subjects for almost a week and for mitigating depression for up to two weeks.

During my career, I (SL) have had the privilege to treat a few people with this ailment and/or similar ones. I remember mostly the issues of treating chorea with antipsychotic drugs. The pathology provided a clinical and an intellectual challenge.

Esketamine (ESK), an s-enantiomer of it, was recently approved for clinical use and is administered by an intranasal spray. It is an easy-to-use emergency intervention for depressed patients, especially for those with overt suicide ideation, plans, and/or behavior.

Treatment with intranasal ESK in conjunction with oral antidepressants can improve depressive symptoms as early as within 24 hours.

Huntington’s Disease (HD) is a "family disease" because it affects the individual diagnosed and also has major implications for any children and other family. Early signs can be subtle, such as mood swings, clumsiness, or forgetfulness. As the disease progresses, chorea, characterized by involuntary movements, becomes more prominent. Cognitive decline, including impaired memory and/or decision-making, adds to the clinical presentation.

Intranasal administration has the practical advantage of being fast, yet less invasive than an infusion. This delivery option is often favored over others. It reportedly is safer and there is more information available about dose/ response and bioavailability. A single dose can yield antidepressant efficacy within a few hours. Suicidal thoughts are reported to have decreased at 2, 4, and 24hour intervals.

A combination of clinical assessments and advanced imaging techniques are utilized to diagnose it. Magnetic resonance imaging (MRI) and computed tomography (CT) scans can reveal specific brain changes associated with it. Genetic testing may be more precise. A blood test

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reportedly can accurately identify the presence of the mutated Huntington gene and thus confirm the diagnosis.

amongst those lacking social support. On moving to the USA, I noticed that many people here live alone, leading to increased depression and susceptibility to ill health.

Its management is multidisciplinary, involving neurologists, psychiatrists, and others. Tetrabenazine can help control chorea and enhance the quality of life. In addition, antipsychotics, antidepressants, anxiety relievers, and anticonvulsants may mitigate symptoms and enhance well-being. Co-existent depression and anxiety often indicate counseling sessions and/or behavioral therapy. Occupational and physical therapy may somewhat preserve mobility and independence.

There is no cure.

I (Dr. Lippmann) have been worried about the effects of too much screen time on kids for most of my career. My parents refused to purchase a television until 1957, despite them being popular in other households for a decade. Excessive screen time is now a national concern, especially with social media, cell phones, and/or computers. The situation got worse during the physical distancing required by COVID-19.

Social connection is a basic requirement for our existence, just like food, water, and shelter. Over time, dependence on each other is critical for survival. We seek social bonds – our brains have evolved for us to be in contact with one another. Despite advancements that enable us to live with fewer interactions, a biological need for connection persists. The structure, function, and quality of our interpersonal relationships affect our health and safety.

Genetic testing provides a definitive diagnosis, but that often precipitates dilemmas. The emotional toll of receiving a positive result can be troublesome. The decision to undergo genetic testing should not be rushed and should be performed along with guidance by genetic counselors. A false positive result and/or a false negative conclusion deserves discussion. Researchers are seeking potential therapies to slow or halt disease progression.

On May 23, 2023, Surgeon General Dr. Vivek Murthy announced his advisory about the public health crisis of loneliness, isolation, and lack of connection. Beyond the harmful mental aspects of loneliness, the problem significantly escalates premature death rates caused by somatic ailments.

Patients may have to make numerous genetic, personal, and therapeutic choices. Compassion, understanding, and a medically holistic approach are essential in supporting these patients and their families.

Loneliness and/or isolation increase the risk of premature death by 26% - 29%. This contributes to mortality as much as smoking up to 15 cigarettes daily. It is linked to a 32% higher incidence of stroke and a 29% increased risk of heart disease. Mental health is also impaired, with an elevated chance to become demented, depressed, and/or anxious. Suicide rates are already at dangerous levels and are rising.

Loneliness: What Our Surgeon General Says To Us By: Amrit Kahlon. M.D., Adil Khan. M.D., & Steven Lippmann, M.D. University of Louisville School of Medicine

Certain groups suffer more than others. Lack of social connection is most prevalent among older persons; however, young adults are almost twice as likely to experience loneliness. The rate of loneliness among young people has risen every year from 1976 to 2019.

Technologies have rapidly transformed lifestyle, work, communication, and socialization. These include smartphones, social media, “screen time”, and especially – since the pandemic – remote work. Despite the benefits of these technologies, they have a tendency to replace face-to-face interactions, monopolize attention, and erode self-esteem.

Most people nowadays think that isolation and/or too much screen time is counterproductive. Recently, there is a resurgence of concern about diminished interpersonal contact.

Having grown up in India within a close-knit family, I (Dr. Kahlon) cherished a close connection with my mother.

She not only fulfilled her maternal role, but was my trusted confidante, with whom I could share my innermost thoughts. As a child, I loved being with friends for play and seldom experienced solitude or loneliness. After coming to the US, I noticed lots of people living and traveling alone, looking at their phones.

The absence of social connection is linked to premature death from many different etiologies. Its effect is comparable to alcohol abuse, smoking, hypertension, obesity, and/or hypercholesterolemia. Social connection reportedly increases survival odds by 50%.

A similar pattern is true for me (Dr. Khan). Growing up in an extended Pakistani family, I was surrounded by loved ones who cared for me and fulfilled my needs. While pursuing medical studies in a different province, I witnessed other students experiencing loneliness with depression One even committed suicide – more common

Cardiovascular Disease People with inadequate social relationships face a 29% higher incidence of heart disease and a 32% greater risk

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of stroke. Patients with congestive heart failure comorbid with isolation have a 68% increased risk of hospitalization, 57% more medical emergency contacts, and a 26% higher rate of outpatient clinic appointments. Individuals with more social connections have a better prognosis during myocardial infarctions, potentially due to the availability of personal assistance.

We need human connections. Seeking to foster more social networking leads to healthier, more productive, and happier lives.

Addressing The Problem Of Isolation After The COVID-19 Pandemic By: Jonathan Ludwig, B.S., 4th year medical student & Steven Lippmann, M.D. University of Louisville School of Medicine

Hypertension One of the leading causes of cardiovascular disease is hypertension. Good social networking is associated with less of it, even among populations at higher risk. Those with such supports evidence a 36% decreased risk of developing it. The National Social Life, Health, and Aging Project documented a potential cause-and-effect relationship between connectedness and more normal blood pressure readings in adults over age 50.

Well over three years since the beginning of the COVID19 pandemic, we are still grappling with its impact collectively and as individuals. A common theme has emerged among my patients. They are lonelier than ever.

One patient on geriatric psychiatry exemplified this finding. I asked him what his thoughts were on returning home. He responded, “If I go home, I’ll end up back here.”

He went on to explain that he had always been alone since the pandemic. His partner and most of his friends had passed. His surviving family only contacted him over FaceTime, as they were afraid to get him sick. But, as he put it, what was killing him was the loneliness and our visits every morning constituted the most consistent human contact he had been having since early 2020. I was at a loss on how to help him; there were no guidelines around treating loneliness, yet doing nothing would only worsen his condition. We had not been treating the underlying condition, only the symptoms.

Diabetes Socialization also influences the onset of type 2 diabetes and its complications. Social disconnection – particularly, living alone, and inadequate social support for men, or lack of emotional support among women – results in an increased rate of developing it. Family involvement has a positive impact on disease management and health outcomes in type 1 and type 2. One national survey revealed that older adults with diabetes with good social support – defined as having at least 6 close friends – experienced a decreased risk of all-cause mortality.

Infections Loneliness augments the development and severity of viral illnesses such as colds and/or influenza. Moreconnected individuals exhibit a 4-fold reduction in the risk of contracting a “cold”. Insufficient socialization with neighbors was correlated with weakened antibody response to COVID-19 vaccines and overt loneliness.

Life has not returned to normal. Social support systems have shrunk, some directly by COVID-19 restrictions or others through the proliferation of video chat, recordings, and social media: the effect is all the same. This concern about loneliness has become so prevalent that the US Surgeon General, Dr. Vivek Murthy, released an “Advisory on the Healing Effects of Social Connection and Community”. He recommends an approach he termed “The Six Pillars to Advance Social Connection”. These are to strengthen social infrastructure in local communities, enact pro-connection public policies, mobilize the health sector, reform digital environments, deepen our knowledge, and cultivate a culture of connection.

Cognitive Decline, Depression, and Anxiety Isolation and loneliness have been linked with accelerated cognitive decline into dementia, including Alzheimer’s disease. Among older adults, those subjects who reported experiencing loneliness exhibited 20% faster cognitive declines. The likelihood of developing depression in adults who frequently report feeling isolated is twice as high in comparison to those who seldom or never feel that way. Social connection provides a protective effect against depression and/or anxiety, even for people who have a higher likelihood of developing affective illness. Suffering isolation is one of the strongest and most reliable promoters of suicidal thoughts and attempts and fatal outcomes.

His report lays out why we should care. To put it simply, decreases in social connection are known to increase the odds of premature death. Connections between isolation/loneliness and cardiovascular disease, diabetes, infectious diseases, cognitive dysfunction, depression, anxiety, substance abuse, etc. are documented. Helping patients to gain meaning through encouraging interpersonal relations induces powerful motivation to reach better health goals.

Loneliness and isolation impair health and well-being, but people can initiate daily actions to enhance their relationships.. For example, telephoning a friend, sharing a meal, meeting with others, and/or performing community service can all improve individual and community health.

How do medical personnel diminish isolationism and promote healthy social relationships in patients? This is Pillar 3 of Dr. Murphy’s strategy, mobilizing the health sector. We must first appreciate that social distancing beyond reason is a threat and combating it should be a

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priority. Sharing that with a patient may be all that is needed to validate their feelings. We can then inform them about community resources that can assist; this would include social connections for at-risk populations, such as veteran’s groups, single-mother sessions, and/or substance abuse programs, etc. We connected my patient with his local VFW post, as he was a veteran and expressed a desire to be around people with shared experiences. He then verbalized hope in meeting new people for the first time in his over three- week-long stay.

There are ways physicians can be helpful. We can use our voice in policymaking and community decisions to promote social infrastructure such as public transportation and parks. Doctors should encourage safer practices surrounding digital media and messaging services, championing protective standards around age barriers, and data transparency.

Before, I had lots of spirit and rose to whatever challenge came before me. At 18, I had emigrated from Russia, caring for my dying mother on my own, despite language and cultural barriers. I gave birth to my son. I had built a robust career as a single mom away from family support, achieving what many said I could not accomplish. I even attained prestigious awards, graduated from university, earned a master’s degree, and had a challenging and rewarding career... all before entering All Saints University School of Medicine. I had always been tough, a survivor. However, my now traumatized brain and body were compromised. Constant pain drained all stamina.

My cognition was sub-optimal. I could not think nor move well. I felt hopeless. My life crumbled while I looked on, unable to intervene.

I eventually found salvation. A wonderful rehabilitation team and old friends responded. No longer alone, I started to process the trauma and the consequent loss of identity. I learned to celebrate every milestone. It took two years to rebuild my body and to re-direct my life. Finally, I recovered enough to graduate from med school. Now, I am seeking placement in a psychiatric residency program.

Isolation has been a public health issue for as long as people have existed. With the advent of social networking, cell phones, and video chats – exacerbated by COVID-19 infection limitations – our society has lost interpersonal connections. Healthcare personnel are in a unique position to help people to feel better and succeed in life.

We have a duty to call attention to the critical importance of social connections. Let’s focus our resources on connecting people so they can help each other be healthier.

This journey taught me that vulnerability is a vital part of recovery. That is a lesson not often taught to budding physicians – that there is strength found in leaning on others.

I now enter Psychiatry with this hard-won wisdom and look forward to helping other distraught people find their way to recovery. Now I have a new story.

My Journey of Recovery By: Viktoria Shihab, M.D., R.D., M.P.H., aspiring psychiatry resident (summer extern) Louisville, Kentucky

Nalmefene: New Opioid Overdose Reversal Drug By: Moji Lawson, M.S, Medical Student, Steven Lippmann, M.D., Emeritus Professor, University of Louisville School of Medicine

Try as hard as I might, I could not get up from the kitchen floor. For over an hour, my back and legs were locked in painful spasms, with my spine frozen in hyperextension. I remained as still as possible, waiting and hoping for the pain to pass enough for me to crawl to a counter and pull myself up. Maybe.

Drug overdose deaths in the U.S.A. have escalated by nearly 30% from 2019 to 2020, a quintupling since 1999. More than 109,000 fatal intoxications were recorded in 2022. Fentanyl overdoses in particular have become a major public health concern nationally. Both authors are troubled by the number of narcotics-related fatalities here in Louisville.

This was my new norm. Walking was slow and excruciating. Bending was worse. I could not function without assistance. Everything changed following my motor vehicle accident in 2019.

Previously, I was an athlete and an aspiring doctor-in-themaking. I was an enthusiastic mother and successful as a career woman. Now, I was just a shell of my former self, trapped helplessly in my body; one that had before been a source of freedom and joy and was now a prison with no end in sight. The car crash took what felt like everything from me: my independence, dignity, momentum at medical school, future financial stability, and the ability to raise my son as planned. This was not supposed to be my story.

Naloxone is the most well-known and widely-prescribed pharmaceutical to counteract opioid poisoning. A common emergency medication indicated to attenuate opioid intoxication, it can delivered by nasal spray. It was approved for prescribing in 2015 and has been effective in diminishing opioid-caused poisoning deaths.

Although medical facilities, families, and the general public should have it available for lifesaving interventions, there are limitations. Its half-life is between 30 - 90

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minutes. Thus, intoxicated persons frequently still experience the effects of a narcotic overdose after the pharmaceutically active quantity of naloxone declines.

For instance, fentanyl is not only more powerful than heroin, but it remains active in the body longer. Often, multiple doses of naloxone are required to fully reverse a fentanyl overdose, - a big problem in emergency departments. Our emergency medicine colleagues, who frequently observe its short duration of action, have talked with us about it.

Though receiving accelerated approval in 2020 (with some political overtones), aducanumab did not reduce clinical signs of dementias, was exorbitant in cost, and evidenced numerous serious amyloid related imaging abnormalities (ARIA). These led to dangers and much controversy.

Lecanemab, another anti-amyloid monoclonal medication, received accelerated approval in January 2023. It also fails in efficacy and can induce adverse events, although reportedly it brings about some reduction in cognitive symptoms.

Nalmefene is a new, longer-acting medication that might help to address this issue. Also administered by nasal spray, it was approved to reverse opioid poisoning in May, 2023. Both medicines work by blocking the effects of opioids in the brain, which can quickly restore normal breathing and blood pressure after an overdose.

Nalmefene’s half-life of almost 11 hours is its main benefit. Theoretically, this reduces the need for repeated naloxone re-administrations and lessens the burden of continuous monitoring. It reportedly also evidences better bioavailability. A unit of nalmefene is priced at about $16, versus approximately $70 for naloxone. It is still not widely available to hospitals nor to community emergency rescue workers.

Donanemab, the newest monoclonal antibody medicine, recently achieved some important safety and benefit endpoints. Fewer ARIA were reported. So far, a request for accelerated approval has been denied. All three of these anti-Alzheimer drugs, besides their prohibitive cost, are documented, at times, to induce considerable morbidity and even mortality.

In phase III TRAILBLAZER-ALZ trial data, donanemab produced a 36% slowing of disease progression on the Clinical Dementia Rating Sum of Boxes (CDR-SB). This is compared to a 27% slowing with lecanemab. About 47% of trial participants who took donanemab evidenced no progression of AD at one year, and plaque clearance at 18 months was documented among 72%. Cerebral edema and/or sulcal effusion (ARIA-E) occurred in 24%.

Over 31% of participants suffered micro-hemorrhages in brain parenchyma (ARIA-H). Nevertheless, only 6% suffered symptomatic ARIA. Though most ARIA proved mild to moderate in degree, more severe abnormalities occurred in 1.6% - and most were resolving after treatment cessation. These figures are significantly better than those recorded in aducanumab studies (though still arguably quite high). Amyloid imaging abnormalities, thus far, appear to be an expected outcome rather than a sideeffect with all pharmaceuticals in this drug class.

With time, the advantages, disadvantages, and differences between naloxone and nalmefene should become clearer. We are hopeful.

Donanemab: A New Alzheimer’s Treatment?

By: Chase Bauman B.S., B.A, Medical Student, Steven Lippman, M.D., Emeritus Professor, University of Louisville School of Medicine

These anti-amyloid medicines provide some new prospect for slowing AD progression and for diminishing psychiatric comorbidities.

I, Chase Bauman, am a third-year medical student interested in Psychiatry. While working as a Spanish language interpreter, I recently met Dr. Steven Lippmann, who was volunteering in primary care at a free, downtown Louisville medical clinic. He suggested that together we write an article about Donanemabe.

Major depressions and psychoses affect a disproportionate number of people with Alzheimer’s Disease. Questions remain: Is depression a comorbid separate condition or a symptom/risk factor for early AD? Does depression worsen cognitive decline and dysfunction in dementia patients? Alzheimer-related depression and psychoses are associated with increased presence of neurofibrillary tangles. Since the amyloid hypothesis of AD proposes that tau and amyloid proteins work synergistically to form plaques and tangles, therapeutics like donanemab might lessen or slow depressive and psychotic comorbidity.

The most common pharmacotherapies for Alzheimer’s Disease (AD) include several cholinesterase-inhibitor drugs and memantine, etc. Though somewhat effective in diminishing cognitive impairment, they fail to halt clinical progression and/or limit amyloid buildup. New IgG1 monoclonal antibody medications seek to remediate Alzheimer’s Disease at a proposed source – to prevent amyloid formation within the brain and to clear existing plaque in patients who are exhibiting early signs and symptoms. A conclusive relationship between amyloid in the brain and intellectual decline, however, is neither well established, nor is it confirmed that clearing plaque will yield clinical progress.

Final conclusions, especially regarding its safety, are not settled. Currently, it has not received approval. Given the known problems with the two previous anti-amyloid monoclonal medications, there is considerable concern about its practical utility and its cost. It would be wise to await final investigational reports – apart from those

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sponsored by the drug companies – to allow a thorough review that does not give in to a marketing push for premature decision to release a safe “cure for dementia”.

Kentucky. In addition, he has a clinical faculty appointment at the University of Louisville Department of Psychiatry and Behavioral Sciences where he is involved in research and teaching resident physicians and medical students. His area of expertise is in interventional psychiatry and the use of transcranial magnetic stimulation (TMS), ketamine, Botox, and other neuromodulation techniques for the treatment of neuropsychiatric symptoms.

These medications give us some optimism for slowing the cognitive deterioration of Alzheimer’s Disease.

Challenges remain with the incidence of ARIA, dangerous potential outcomes, and high financial cost. Only further investigations and patient-related experience will tell how effective and safe donanemab will be in improving the lives of people with AD.

Dr. Farooqui received his undergraduate degree and medical doctorate at the University of Kentucky. He did residency training in neurological surgery at the University of Missouri, and then completed a residency in Psychiatry at the University of Louisville. In addition to his community service work, he has held administrative, leadership, and consulting roles in numerous professional and healthcare organizations.

Daniel Dahl, MD

Laurence H. Miller, MD, DLFAPA

Dr. Dahl graduated from Northwestern University and then the University of Nebraska Medical Center. He completed a Psychiatry Residency at UAB and also has additional qualifications as a Geriatric Psychiatrist. He worked for 11 years in private practice before going to University of Alabama - Birmingham as the Psychiatry Residency Training Director. He subsequently became Vice-Chair for Educational and Clinical Services. He is now a Supervising Psychiatrist at the BVAHCS.

Laurence H. Miller, M.D. (Larry) lives in Little Rock with his wife, Anne, where he is a Clinical Professor of Psychiatry at the University of Arkansas for Medical Sciences (UAMS) and Senior Psychiatrist in the Division of Medical Services (Medicaid) at the Arkansas Department of Human Services. Originally from Boston, they moved to Little Rock in 1994 for him to assume the position of Medical Director at the Arkansas State Hospital and for him to join the faculty at UAMS. He served as Medical Director until 2005, during which time he was also appointed as Medical Director of the Arkansas Department of Mental Health and Director of the Arkansas Mental Health Research and Training Institute (1996 - 2012). In 2013, he began his current position at Medicaid. At UAMS, he teaches and supervises faculty and residents in psychodynamic psychotherapy and sits on several residency and department committees.

He loves to see patients and to teach.

He is actively involved in the Arkansas Psychiatric Society as its Nominations and Elections Committee Chair and Senior Advisor. He is a past President and represented Arkansas in the APA Assembly for 11 years before being elected its Area 5 Deputy Rep and then Rep. He is also a recent past Chair of the APA Committee on Reimbursement for Psychiatric Services and a past member of the Council on Healthcare Systems and Financing.

Ali A. Farooqui, M.D. Dr. Farooqui is a private practice psychiatrist at Integrative Psychiatry in Louisville, psychiatrist director of the Louisville Metro Department of Corrections, and a consultant for legal practices and District Courts in

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He graduated from the University of Vermont, received his M.D. from the Chicago Medical School, served a Rotating Internship at Rhode Island Hospital and completed his Psychiatric Residency at Boston University. He is Board Certified in Adult Psychiatry and is a Distinguished Life Fellow of the APA.

LETTER FROM THE EDITOR Where is Everybody Else?

By: Bruce Hershfield, MD I really enjoyed this year’s meeting in Huntsville. It was well-planned and wellcoordinated and the lectures and discussions were interesting.

The parties – including the gala – were fun. The people in Alabama – a place I had never been – were very pleasant. The US Space & Rocket Center was a special venue for our Friday reception. My son, who gave one of the talks, made it clear he understood why I always attend, and he asked about coming to next year’s meeting in Chattanooga.

After his residency, he served as a Lt. Commander in the U.S. Public Health Service and then returned to BU, where he served as Senior Inpatient Psychiatrist and then Director of the Emergency, Screening and Outpatient Department at the Solomon Carter Fuller Mental Health Center. From there, he moved to Boston City Hospital, where he developed a geriatric psychiatry unit and clinic and then ultimately became Director of the Division of Psychiatry.

There were about 105 attendees and only about 40 were SPA members. These are typical figures for our meetings.

In MEMORIAM:

So, where was everybody else? Woody Allen said that 80% of life is just showing up. The Southern is an organization that is based on the support and friendliness that members display to each other. To prosper, we have to show up.

C. DUANE BURGESS, MD By: Bruce Hershfield, MD

I have heard lots of explanations. I know they are valid.

We seek out new members who are successful, and they tend to be busy. It’s expensive to drive or fly a few hundred miles and to stay in a hotel. Our membership is getting older and there are medical problems to consider when thinking about traveling after a certain age. Younger members want to spend their time with their families when they are not at work.

What would make it worthwhile for our members to get together? The old model, based on what worked when folks traveled by train to get the information that was hard to get any other way, has been going the way of old models everywhere (and going there faster and faster).

On August 16th, Dr. C. Duane Burgess, a long-time SPA member, died at age 91.

Originally from Mississippi, he attended junior college, college, and medical school there. After his psychiatric residency, he served in the military at the US Treasury, evaluating secret service agents.

What will it take? Would some members attend virtually if they can’t attend in person?

We need some suggestions on how we can change. Let’s address this one before the next meeting.

In addition to having a private practice in Hattiesburg, which he started 1967, he founded the psychiatric wing at Forrest General Hospital, worked as Chief of the Medical Staff at Bryce Hospital in Alabama, and served on the staff at Ft. Sill, OK. A Distinguished Life Fellow of the APA, he had the honor of having at least two buildings named after him – at Southern Mississippi Regional Center in Long Beach, MS, and Pine Grove Psychiatric Intake Care Unit in Hattiesburg.

As Dr. George Wilkerson of Hattiesburg commented on his obituary page (from which this information was taken), “A wonderful man. I was one of the psychiatrists he recruited. He was a great teacher. He will be missed.”

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SPA OFFICERS 2023-2024

SAVE THE DATE 2024 Annual Meeting

President: Mary Jo Fitz-Gerald, MD President-Elect: Rodney Poling, MD Vice President: Raymond Kotwicki, MD Secretary-Treasurer: Jenny Boyer, MD Board of Regents, Chair: Felix Torres, MD Board of Regents, 2nd Year: Chasity Torrence, MD Board of Regents, 1st Year: Rahn Bailey, MD APA Assembly Representative: Mark Wright, MD Immediate Past President: Thomas Franklin, MD Executive Director: Janet Bryan

Chattanooga, Tennessee Partnering With the Tennessee Psychiatric Association September 11 – 15, 2024 The Westin Chattanooga Hotel

“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 Larry Miller, MD Editor: Bruce Hershfield, MD Assistant Editor: Janet Bryan

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