SOUTHLANDS The Newsletter of the Southern Psychiatric Association Volume 7, Number 2 DECEMBER 2021 Article Title Greetings From the Outgoing President The President’s Column Executive Director Update David Casey, MD – Our New SPA President Welcome New Member – Gurpreet Singh Guliani, MD Mark Wright, MD Elected SPA Assembly Rep Some Snippets of the SPA/ APPA Annual Meeting Report on APA Fall 202 Assembly Interview: Mary Jo Fitz-Gerald, Speaker of the APA Assembly Six E’s of How to Address Racism in the COVID-19 Era Should We Challenge Misinformation? Reflections on the COVID019 Pandemic from the Perspective of a Psychiatric Resident Humor and Psychiatry The CMS Final Rule 2022 – Where It Stands Now
Author Margaret Kea Cassada, MD David Casey, MD Janet Bryan Mary Helen Davis, MD
Influencing Decision Making in Congress Good News: No Aluminum is in Current COVID-19 Vaccines Monoclonal Antibodies Casirivimab and Imdevimab
Kenneth Busch, MD Steven Lippmann, MD Aya Allam, MD and Steven Lippmann, MD Aya Allam, MD and Steven Lippmann, MD Gurpreet Singh Guliani, MD and Steven Lippmann, MD Amal Mumtaz, MD and Steven Lippmann Srija Chowdary Vanka, MBBS & Steven Lippmann, M.D. Muruga Loganathan, MD & Steven Lippmann, MD Aya Allam, MD and Steven Lippmann, MD Bruce Hershfield Jay Scully, MD Bruce Hershfield, MD
ADUCANUMAB: Risk-to-Benefit in Alzheimer’s and Trust in the FDA Is Ivermectin Really A Good Idea? What Neuropsychiatric Issues Come With COVID-19? COVID-19 and Substance Abuse Borderline Personality vs Bipolar Disorder REMDESIVIR: Is It Worthwhile? In Memoriam: Dr. Harold Eist In Memoriam: Dr. Daniel Winstead Letter from the Editor: The Rose Save the Dates: 2022 Spring Reception, 2022 Annual Meeting, 2023 Annual Meeting
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Gary Weinstein, MD Bruce Hershfield, MD Mark Komrad, MD Bruce Hershfield Rahn Bailey, MD Jenny Boyer, MD Arthur Albert Olivia, MD and Mary Helen Davis, MD Shree Vinekar, MD Ronald Burd, MD
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Greetings From the Outgoing President By: Margaret Kea Cassada, MD
(gasp!) hugs. I need that, as much – If not more – than I need the CME from our excellent meetings! I wish all of you a healthy and happy 2022, and I hope to see all of you in Baltimore!
Happy Holidays, Southern Psychiatric Association! It has been an honor to serve as your president and to turn the reins over to Dr. David Casey for the next term, for what I hope will be a one-year commitment.
The President’s Column By: David Casey, MD
As this is my last presidential letter for Southlands, I want to start with several “thank you’s”. First, we have a wonderful executive director in Janet Bryan. She makes those of us in elected positions look good with her competent management of our meetings and the daily affairs of the organization. Second, thank you to all the officers who agreed to serve two years in their positions because of the pandemic, ensuring the continuity of this organization. To our membership: for sticking it out through unprecedented changes to the world, as well as our new virtual meetings. I know the new format wasn’t perfect, but we learned so much from the process and are much better prepared for adversity in the future. And finally, to Dr. Bruce Hershfield, for his dedication to keeping this newsletter going and gently prodding contributors to get their submissions in!
I’m honored to serve as the new President of the Southern! I look forward to an exciting and productive year, with a plan for an in-person meeting in Baltimore next September. Because I have missed our usual opportunity for personal interaction, I am looking forward to returning to meeting people face-toface again. We can only hope the pandemic will not interfere. Thanks are due to our outgoing President, Dr. Cassada (now our Immediate Past President) for her work, which unexpectedly had to be extended for an extra term because of the pandemic. For those of you who don’t know me, let me introduce myself. I am a professor and Chair of the Department of Psychiatry and Behavioral Sciences at the University of Louisville, and I also have the John J. and Ruby Schwab Chair in Family, Social, and Community Psychiatry. I attended medical school at U of L. I did a medical internship at the Virginia Mason Hospital and my psychiatry residency at the University of Washington, in Seattle. Louisville is my home town. My clinical practice is in geriatric psychiatry. I’ve previously served in other offices of the SPA, and have presented at the annual meeting on several occasions.
Dr. Hershfield asked me to reflect on my experience as president. There are the usual, presidential things that I am happy about – our association’s finances are solid, we have increased our membership, we continue to enjoy strong relationships with several state psychiatric associations, and we are well-represented at the APA. But the first word that came to mind was… “weird”. It has been a weird two years. I had certain goals I had hoped to accomplish in this role, but those were upended by the pandemic. I am a rural Southern physician, treating rural people, and I count on organizations like the Southern to relieve my isolation from psychiatric peers. (My nearest colleague in the Southern is over 70 miles away!), It also provides me with updated, useful scientific information. Usually this happens in person, on location, somewhere in the region we represent. The transition to online “everything” was jarring. Even with faces on screens, the dehumanizing effect of technology tends to chill collegiality, and stifle meaningful debate. (At least, that has been my experience.)
I have been involved in many psychiatric, medical, and community organizations. I’m a Distinguished Life Fellow of the APA, where I have served on various committees. I also served as Treasurer and Vice-President for SPA– plus two terms as President of the Kentucky Psychiatric Medical Association. In addition, I have been, for many years, President of the Innominate Society of Louisville, a medical-historical group. Several of my talks at the Southern and elsewhere have been on historical topics. My wife, Valerie, recently retired as director of the Women’s Center at U of L. We have four adult children, two of whom are academic physicians. (One is a psychiatrist at U of L).
I worry about the future of Psychiatry – which depends heavily on the real bond and rapport between people – if the use of technological intermediaries becomes the norm, and not a temporary stopgap. Also, without inperson meetings, I wonder whether professional organizations will be useful in the future. Sitting behind a screen, humans tend to get more insular and entrenched in their worldview, political views, “consensus”, “settled science”… I don’t think we need more of that. We need to robustly debate, to maintain a healthy skepticism, and to be part of our communities. I certainly hope that our future will include all of that, as well as handshakes and even
I’m very excited about this opportunity and look forward to meeting many more of our members!
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Executive Director Update By: Janet Bryan
David Casey, MD Our New SPA President By: Mary Helen Davis, MD
Another year has passed by without an in-person meeting; however, we had a successful virtual event in October with the Alabama Psychiatric Physicians Association. There were 74 people registered, and the meeting ended with a profit. We were very fortunate to have nine exhibitors. Please see the attached exhibitor newsletter for information on each sponsor.
It is a great pleasure for me to tell you about our next president, Dr. David Casey. Many of you had the pleasure of meeting him when he spoke at our last in-person meeting in Louisville, in 2019. Perhaps you recognized his talents as a guitarist and singer in the University of Louisville Department of Psychiatry’s Rock Band (known as NOS), which provided our farewelldinner entertainment.
Because the Annual Meeting could not be held in person, the Executive Council decided to hold a virtual business meeting on November 15. At that meeting, new officers were elected and the bylaws were updated. Bylaws changes included allowing for business meetings to be held virtually and for combining the Future Sites and Long Range Planning Committees. The new combined committee, which will be chaired by Dr. Mary Helen Davis, is in the process of forming. Please let me know if you are interested in joining.
I have known him for nearly 40 years as a friend and colleague. He is one of the rare “renaissance men” in our field. He is a man of broad knowledge – not limited to clinical and scientific topics – he has multiple interests (that he can pull up providing an eloquent oration faster than most of us can conduct a google search), and he is cultured in the arts, and he paints as a hobby. He is always personable and charismatic.
Below are the officers who were voted in at last month’s meeting: President: David Casey, MD President Elect: Thomas Franklin, MD Vice President: Mary Jo Fitz-Gerald, MD Secretary/Treasurer: Rodney Poling, MD Board of Regents: Chair: Abhinav Saxena, MD 2nd Year: Lauren Pengrin, DO 1st Year: Felix Torres, MD APA Assembly Representative: Mark Wright, MD Immediate Past President: Margaret Cassada, MD
He has been Chair of the Department of Psychiatry and Behavioral Sciences at the University of Louisville School of Medicine since 2015. He is a geropsychiatrist by training and he founded the first dedicated geropsychiatry unit in the region. He is the author of over 50 publications, primarily in geropsychiatry, and is a highly sought-after speaker. In addition to clinical geropsychiatry, he lectures on the history of Psychiatry, including case histories of famous individuals. He has developed a book on the psychiatric history of the Lincolns, tracking concepts of mental illness over time. He is widely respected as an educator, clinician, researcher, and administrator, excelling in each of these domains . I hope when we get together in person at either our reception at the APA Annual Meeting in New Orleans, or the SPA fall meeting in Baltimore you will have the opportunity to get to know Dr. Casey better, as well as to meet his lovely wife, Valerie. In addition to successfully raising four children who are now young adults (one now an early-career psychiatrist), they have collaborated on global trips for U. of L. undergrads to Peru, Spain, Cuba, India, and Morocco. David, an intrepid lifelong learner, has recently taken up Spanish and now serves as a translator.
I am excited to report that PRMS will partner with us to host a reception at the Spring APA meeting in New Orleans on Sunday, May 22, from 6:00 p.m. to 9:00 p.m. Please hold the date on your calendar – additional information will be sent as soon as it is finalized. Since our last in-person event in August of 2019, we have not had the opportunity to connect with our colleagues. I am wondering if we should sponsor a few evening virtual events during 2022 to allow us to remain in contact and to allow easier networking. Please email me if you would be interested at jbryan@sheppardpratt.org Dues notices were mailed earlier this month and are due in January. Please let me know if you did not receive your notice.
We have reason to be optimistic as we head into 2022, led by David and our other officers.
Wishes for a wonderful holiday and Happy New Year. I look forward to seeing everyone next year!
WELCOME NEW MEMBER Gurpreet Singh Guliani, MD Dr. Guliani received his M.D in Psychiatry from the Govt Medical school and hospital in Amritsar, Punjab,
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India. He then worked as a consultant psychiatrist at different locations in India. He is currently working as a Fellow in Addiction Psychiatry at the University of Kansas.
Some Snippets of the SPA/Alabama Psychiatric Association Annual Meeting October 7-8, 2021 By: Bruce Hershfield, MD
His professional interests focus on psychopharmacology and addiction psychiatry. His current projects include studying buprenorphine to find the best dosage in the elderly. In addition, he is interested in teaching medical students. He will be looking to complete a general psychiatry residency in the USA.
1) Community-Based Social Determinants, Resilience & Recovery by Jacqueline Maus Feldman, MD She talked about the social determinants of mental illness and defined resilience as the ability to bounce back from & to thrive as a result of meeting major challenges. 2) Mental Illness & Health Equity by Timothy Stone, MD The Surgeon General’s Report more than 20 years ago described the health disparities between the races. In 2017 African-American people in the USA had lifespans 4 years shorter than whites, and this difference was more marked among men. Social determinants are more important in causing this disparity than the medical care patients received.
Mark Wright, MD Elected SPA Assembly Rep By: Gary Weinstein, MD On November 15th, Dr. Mark Wright was elected the SPA Representative to the APA Assembly. He will be on the Assembly Committee of Representatives of Subspecialties and Sections (ACROSS), which includes the SPA and 19 other groups.
3) Ethics & the COVID-19 Pandemic by Rebecca Brendel, MD (APA President-elect) She listed the 4 principles of ethics: autonomy, beneficence, nonmaleficence, & justice. Factors affecting the high death rate among African-Americans include housing problems (more high-density), pre-existing conditions, employment, and lower wages without benefits. The situation is worse in those states that had slavery up to the Civil War and those states that still lack the Medical Assistance-expansion engineered by the Affordable Healthcare Act. Take-home points include: 1) avoid seeing choices as simply binary, 2) know your resources, and 3) the public needs to be educated about getting vaccinated and using masks. One question she fielded had to do with what to do about colleagues who continue to spread false information.
Dr. Wright graduated from the Marshall University School of Medicine and completed his Psychiatry Residency and Child Fellowship at the University of Kentucky. He has been in practice in Lexington for 22 years, providing care in a variety of settings. Widely respected in the medical community, he has been an important member of the Kentucky Psychiatric Medical Association since his first year of practice. He has been President for two terms and Chair of the Scientific Research Committee since 2009. He was its Assembly Rep from 2005-2021, and made significant contributions to Area 5, which is the largest Area in the Assembly and includes the southeastern states and several other important groups.
4) Maintaining Proper Professional Boundaries by Stephen Lloyd, MD. He cautioned about using social media, warned not to treat friends and family members, and pointed out the necessity of controlling who uses your prescription pads.
He is highly regarded in the Assembly, whose definition is that "it recommends actions to the Board of Trustees". It actually has been the origin of many of the policies and procedures that guide the entire APA, and is the best place for members to discuss and debate issues relating to our patients and the profession. For many years it has been the most important APA group for leadership training; the majority of members of the Board of Trustees are often past Members of the Assembly.
5) New Antidepressants & the Pipeline: Where are We Going? By Richard Shelton, MD. He talked about ketamine and combinations of dextromethorphan and quinine, and reminded us that the depressed brain loses synapses when stressed. Ketamine rapidly restores “spines” and synapses; the question is whether we can prolong the initial response. Side effects include dissociation, dizziness, nausea; no safety trial has extended beyond 60 days. It is hard to use in practice, partly because of the REMS mandate. Other research topics include glutamate, the NMDA-glycine site agents, and psilocybin.
Dr. Wright, who is now Chair of our Program Committee, has already contributed a lot to the SPA. Anyone who has an idea to better guide APA policy can discuss it with him to see how it might be shaped into an actionable task for the Assembly to consider. We are fortunate to have someone with his experience and skills to guide us and to represent our interests.
6) Preventing Violence, Seclusion & Restraints in Psychiatric Hospitals by Sylvia Atdjian, MD. Workers in inpatient psychiatric facilities suffer the 2nd highest rate of violence in the workplace (behind law enforcement
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officers). Of the violence, 71% is “affectively driven” instead of planned. Most state hospitals have stopped using seclusion and restraint. SAMSHA gave money for training in 45 states between 2002-09. The 6 core strategies include training everyone who interacts with patients (including peers, families and advocates). She addressed questions about eliminating seclusion and allowing restraint only in emergencies – to prevent imminent physical injury.
11) Mass Incarceration & the Mental Health Crisis in America’s Prisons by Charlotte Morrison, Esq. of the Equal Justice Initiative. In 1989 Alabama had 25% of the country’s executions. Less than 2% of if its counties produced the majority of its death row inmates. In 1972, 75% of those executed in the South were AfricanAmerican. Those convicted of killing white people were far more likely to be executed. Alabama continues to sentence more people to death than any other state. There are 2.3 million inmates now, compared to 300,000 in ’72. The increase in the rate of incarceration of American women between 1980 and 2017 was almost 800%. Millions of children lose a parent to incarceration; and this rate is much higher among the African-American population.
7) The Resident Research Award: “The Impact of Bariatric Surgery on Psychiatric Disorders: A National Cohort Study” by Ari Morgenstern, MD. Psychiatric disorder rates can increase after bariatric surgery. He used a data base of 30 million to find a group of 56,661 patients (and a matched control of the same number). The rate of disorders requiring inpatient care was 22% higher and the overall risk for any mental disorder was up by 27%, in those who had bariatric surgery.
12) “Diversity & Inclusion 2021 by Roger Smalligan, MD In Alabama, only 5.8% of physicians are AfricanAmerican, so the University of Alabama is trying to recruit more minority students into its medical school. (About 7% of its students are currently members of minorities). Programs include “Learn Everything about Patients” – one week on the campus for high school students – and an 8-week program in each of two summers for college freshmen and sophomores.
8) COVID-19: Update by Sandra Fryhofer, MD. She pointed out that hesitancy to get vaccinated is not the same as refusal. Some people do not have access to the technology and the vaccines have been distributed unevenly. The Pfizer & Moderna vaccines are mRNA & the Janssen is a “viral vector” one. The first two can cause myocarditis & pericarditis, but these are more common with COVID than with the vaccines. The Janssen vaccine can cause thrombosis & thrombocytopenia syndrome (“very, very rarely”). The delta variant is more than twice as contagious as the alpha one. The 3rd dose should be given at least 28 days after the 2nd Pfizer or Moderna; these are considered “additional primary doses”, not “boosters”. COVID survivors definitely need to get vaccinated. Patients can get infected more than once. People can get their flu vaccines and their COVID vaccines at the same time.
Report on the APA Fall 2021 Assembly By: Mark S. Komrad MD Representative for the SPA to the APA Assembly In November, 2021, once again, the APA Assembly met virtually. Pursuing politics on Zoom is always a challenge, but much was accomplished.
9) The 6 “E’s” & How to Address Racism in the COVID19 Era by Rahn Bailey, MD. These are “engage, empower, explore, empathize, evolve, and embrace”. He pointed out that Nelson Mandela’s “Truth & Reconciliation” project in South Africa really helped that country heal. There are challenges ahead, but people must believe they have the chance to do whatever anyone else can do.
Dr. Saul Levin reported on the state of the APA. A few points that may be of interest to SPA members: • There continue to be aggressive attempts in many states to increase the scope of practice of psychologists, nurse practitioners, and physician assistants (who are changing their name to “Physician Associates”!) PA’s and NP’s are seeking authorization to independently authorize involuntary civil commitments, perform competency assessments, and even to write lethal prescriptions for assisted suicide, all without physician supervision. Currently psychologist prescribing bills are on deck in FL, PA, and MD. The APA, together with the AMA and other specialty organizations, is battling this on a state-by-state basis through its district branches. This is a “state-level” battle at this time, rather than federal. The point of departure in the APA’s message is that this is a patient protection issue, not a “guild protection” one. • DSM-TR, the next text revision of the DSM, will be released in March. Diagnostic markers, risks of suicide,
10) Decolonizing Psychiatry by Ayesha Khan, PhD. African-American & Indigenous people have the highest COVID-19 death tolls. Ischemic heart disease is the #1 killer, and CVA causes the second highest number of deaths, in the world . Most people who live in the US are still foreign settlers ruling over a land we did not initially populate. Poverty rates among children, limited access to health care, disability rates, and inability to afford medical care still differ among the races. We need to address the root causes of bad health – societal problems, not just individual ones. We need to do away with the vestiges of colonialism and take a more holistic approach.
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differential diagnosis, associated features, prognoses, and other information will now be included for listed conditions. The language was also re-evaluated to be as race-neutral as possible.
• The APA will develop a toolkit providing resources to advocate for a change in professional board licensing applications, as well as hospital and organizational credentialing, in order to destigmatize mental health and enhance help-seeking by physicians.
• The APA is collaborating with CMS to develop a collaborative care model to more deeply integrate psychiatrists with primary care clinicians. •
• The APA is directed to develop an evidence-based position advocating for the decriminalization of personal use and possession of illicit substances.
The APA joined 7 other specialty organizations to declare “a state of mental health emergency” due to the Covid-19 pandemic.
• The APA will advocate that participating in the articlebased Part III in the ABPN’s Maintenance of Certification (MOC), will be sufficient to satisfy the selfassessment requirements.
• In this era of ransomware attacks, the organization now has a digital security expert on staff, to minimize the risk of such cyberattacks.
• Several papers were passed addressing structural racism. One directed the APA to educate its membership, the public, and its leadership on “racebased tokenism.”
• The Assembly is responsible to approve original or revised Position Statements of the APA. Some positions approved that may be of interest to SPA members include:
• The APA will develop a comprehensive plan to reduce its carbon footprint for the annual meetings.
• National standard to protect children and adolescents against violence and harassment by law enforcement responding to youths who are in a mental health crisis.
• “Suicidal Behavioral Disorder” will be removed from Section 3 of the DSM.
• Insurers should recognize that physicians have autonomous clinical decision-making authority to prescribe FDA-approved drugs or medical devices for off-label indications. This should be reimbursed by insurances and authorized without exception, if the agents are in the formulary, regardless of formal FDA indications. •
APA supports and offers specific measures to address and support clinician mental health and to mitigate moral injury that has occurred during the COVID-19 pandemic and for future pandemics.
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Psychiatry residents and fellows should be supervised by psychiatrists in conducting psychiatric diagnostic evaluations, managing psychiatric emergencies, and using medications, and not be supervised solely by advanced practice clinicians.
• The APA will develop a mentorship/sponsorship program for international medical graduates to foster professional growth and involvement in the organization. Any APA member can develop an action paper and promote its passage in the Assembly. You can contact the Assembly Rep for your district branch or Dr. Mark Wright, the new Rep for the SPA, to help you structure it and to shepherd it through the Assembly’s processes.
Interview: Mary Jo Fitz-Gerald, MD Speaker of the APA Assembly October 28, 2021 By: Bruce Hershfield, MD
• The decreased barriers to the use of telemedicine for psychiatric treatment should be continued permanently, and should continue to be reimbursed at parity with in-person treatment.
Q.: "Tell us about your work in the Assembly and about your leadership roles in American psychiatry." Dr. F: “I really love the Assembly, as we have a chance to influence psychiatric care, our profession, and our organization. Members of the Assembly and APA Staff are wonderful to work with and make my work easier and better. The Speaker has to make sure the meeting runs well and all items are covered sufficiently in the discussion. This is especially difficult in Zoom because we don’t see who is “walking up to the mike.” Fortunately, Drs. Nelson, Pozios, Benson, Anzia, Batterson, and APA Staff (Allison Moraske and Monique Morman) are there to help me call on individuals in order. My initial practice as Speaker was declaring “a quorum” and asking for missing
In addition to crafting and reviewing APA Positions statements, members of the Assembly generate “action papers,” directing the organization to pursue certain actions. A few passed that would be of interest to SPA members, including: • The APA will develop a position statement regarding the interface between psychiatrist reviewers and treating clinicians to create national standards for fairness and professionalism by those psychiatrists who do reviews to authorize ongoing treatment.
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Assembly representatives in my role as Recorder. Shortly after I became Speaker-elect Joe Napoli became ill; this meant I became both Acting Speaker and SpeakerElect. The lack of his presence and leadership was felt by all. His death prior to the Spring 2021 meeting left a void in all of our hearts.”
presentations rather than written. I worked with PhD members of our department on their research projects. During the ‘90’s and early part of the 2000’s I participated in several drug trials. Last year I co-edited a textbook, “Models of Emergency Psychiatric Care That Work”, which discussed models of emergency psychiatric care in the US and in other countries. My clinical work encompassed inpatient, outpatient, emergency, and consultation liaison roles at different times.”
Q: “Yes, that was sad. What have you found useful as preparation for your role as Speaker? Dr. F: “I found the media training that the APA provided in the past useful in many ways. I learned not to use filler sounds like “er”. When the really good speakers are talking they have a tendency to repeat themselves – they can use the same phrase over and over again instead of using filler words such as “you know” and “so.” The repetition allows time for these speakers to think of their next words and give emphasis to what was just said. Toastmasters International membership is a great way to develop speaking and leadership skills.”
“I did recently step down from my full-time position at the medical school, though I do cover weekends at our sister hospital, about 100 miles away, by telepsychiatry.” Q: “What are your plans for the future, and how can we help you achieve what you are hoping to do?” Dr. F: "I am a certified physician’s coach now – I completed my training a couple of weeks ago. I try to help physicians and other healthcare professionals function better and to avoid burning out. There is a “great resignation” going on in the country; it’s not surprising that many physicians are looking at what is most important and deciding how to re-evaluate their careers."
Q: ”What was being Chair of the SPA Program Committee like?" Dr. F:” Janet Bryan is wonderful! She took us from planning an in-person meeting to a virtual one this year within a few weeks’ time. The meeting went very well. Mark Wright was a great Co-Chair and pulled a lot of weight when I was overwhelmed with other duties. He will do a great job as Program Chair with Phil Scurria for next year. The meeting was in conjunction with the Alabama Psychiatric Physicians Association. Dr. Clinton Martin brought the influence and opinion of the Alabama Psychiatric Physicians Association to the Program Planning Committee.”
Q: “We are very fortunate to have you in these leadership positions. You are one of those people willing to work hard to contribute. You do so much for our profession!” Dr. F: “Thank you.” The Six E’s of How to Address Racism in the COVID-19 Era By: Rahn Bailey, MD and Raj S. Patel, BA
Q: ”Yes, I also thought we worked together very well. It was particularly impressive, given the untimely death of Paul O’Leary, who was so important.” Could you tell us about how you came to be a psychiatrist and about the people who most influenced you along the way?”
Since the beginning of 2020 the world has experienced a new era, defined by COVID-19. The normalcy of social distancing, facemasks, and COVID-19 vaccination cards being a requirement to participate in many public activities, are examples of the social differences that have taken place. The most impactful of those differences are the ones pertaining to race relations. Laurencin et al claim that “racism and COVID-19 represent a pandemic on a pandemic for Black people”. This racial disparity also extends to Latinx and Native American populations. As disheartening as this may seem, the 6E’s of how to address racism in the COVID-19 era provide a framework upon which racism can be fearlessly confronted, understanding can effectively be reached, and realistic changes can be made. For clinicians to effectively deal with racism in the COVID-19 era they must Engage, Empower, Explore, Evolve, and Embrace to enact positive changes.
Dr. F: “One of the Attendings during my junior year of med school was very helpful. He was humorous, he was lively, and he was more personable than a lot of other attendings we had. He had us to his house for barbecue and told us about his role as Tevye in “Fiddler on the Roof.” I realized that if I went into Psychiatry that I would have a chance to pursue lots of different activities – and not be “just a doctor.” In terms of my involvement with the APA, I consider Dudley Stewart and Dan Winstead to have been wonderful teachers. I miss them a lot!” Q: “Tell us about the research and teaching you did while you were on the medical school faculty full-time for 33 years.”
The first E of the six is Engage. Engaging with any behavior is the primary step in discerning what it is. Healthcare providers should engage racism when it is encountered because “research has identified racism as
Dr. F: “A lot of my work was based on presentations I did at national meetings. I felt more comfortable with oral
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a fundamental or root cause of health inequalities”. This is significant because, according to Wilder et al, “our unwillingness to confront the issue of racism in healthcare head-on will continue to impede our ability to achieve true health equity”. If a situation has a racist tone, it is better to engage each other in open discussion. This allows us to understand why a situation is occurring in a specific manner, and how it can be addressed constructively. An example of facing racism through a lens of productive engagement is Nelson Mandela’s Truth & Reconciliation Commission (TRC), started after his release from imprisonment after 27 years. The TRC was formed in 1995 “to investigate human rights abuses during the apartheid era, and it exposed the horrors of systemic torture, political oppression, and economic deprivation”. The TRC still exists and helped to usher in an era of greater fairness and humanity in a country defined by rampant segregation, much like the United States. Like the TRC, healthcare providers should aid patients by giving them the tools necessary to confront racism.
that “the sin of racism affects us severely and deeply, yet we remain silent or in denial, a response we learned from our ancestors for whom silence meant survival”. It becomes clear that without a proper exploration of the racism that African Americans endure, more suffering can occur. Healthcare providers should remember that it may be difficult for patients to address their past traumas. Multiple attempts to explore this may be necessary before any noteworthy progress is made, lessening the harmful effects of “causing our racial trauma to accumulate, which contributes to a more insidious chronic stress”. After Exploring a patient’s racial trauma, it is imperative to Empathize with them. This is the ability to understand and vicariously share the thoughts and feelings of others. Empathy is inherent to medical practice. Healthcare providers should keep in mind that the higher instance of segregation within the USA compared to many other countries, contributes to higher rates of COVID-19, and subsequent COVID-19-related trauma. This means that oftentimes members of the minority communities have had an entirely different experience through the current pandemic than others have had. This should be a factor when attempting to empathize with them. Furthermore, providers should always be vigilant of their own internalized biases. Forgiarini et al state that “even if we are not aware, our body and our mind use internalized knowledge to address reactions and activities they engage to deal with [the] social and physical world”. Furthermore, it is important to be able to empathize with all parties involved in racially charged situations. Sometimes, the perpetrators of racist micro-aggressions are acting out of ignorance rather than maliciousness. Such icons as Mahatma Gandhi, Martin Luther King Jr., and Nelson Mandela empathized with the racially oppressed as well as with those who were passive due to their ignorance.
To effectively Engage, one must be Empowered. Healthcare providers should acknowledge that African Americans are being hurt right now. The most relevant example in the current socio-political climate that disempowers African Americans is the slogan “All Lives Matter” in response to the Black Lives Matter movement. While it is true that all lives do in fact matter, the phrase “All Lives Matter” has been weaponized to take on a meaning that detracts from the message that Black Lives Matter. “All Lives Matter” implies a failure to comprehend that African Americans, specifically, in the USA, are still mistreated and regularly suffer from structural racism that is embedded into the very fibers of “normal” societal life in the country. It is harmful because it devalues the experiences of so many African Americans who have experienced racism and “is seen as a direct push against the Black Lives Matter movement often dismissing, ignoring, or denying these police-brutality related and racially-motivated incidents against black individuals”. Furthermore, it undermines open dialogue and hampers efforts towards understanding. Additionally, resources should be given to patients to help in dealing with racism. One key factor is making sure that patients know that they are not alone. Their experiences are not anomalies, and other people have experienced similar instances. Patients should know that they are a part of an empowered community, and this sentiment should be reinforced by their healthcare providers.
The most transformative of the 6 E’s is making the commitment to Evolve – to refuse to remain stagnant and to be defeated by racial mistreatment or marginalization. Evolving is a necessary development for any person hoping to heal from trauma. Many factors have historically worked against members of these minorities. For example, “data suggests that [African Americans] experience chronic illness and mental health challenges at higher rates than white Americans”. It is often easier to slip into detrimental mindsets when one experiences “harmful ecological environments, characterized by densely populated areas, concentrated economic disadvantage, high crime rates, few healthy food options and green spaces, and subpar housing”. But people can improve their abilities and develop new ambitions. Healthcare providers should encourage this growth by helping patients to set attainable goals and discussing how best to achieve them. This helps to direct the change that evolution brings in a positive and constructive manner. The Evolution that occurs is the culmination of Engagement, Empowerment, Exploration, and Empathy working in tandem to enrich an individual’s life.
After Empowering patients to express and assert their stance on an issue, it is important to Explore these views. The exchange of information that can occur between a clinician and a patient during this time can allow for an investigation of racially charged topics that may have been repressed or avoided. In her book Healing Racial Trauma: The Road to Resilience, Sheila Wise Rowe mentions that “people of color have endured traumatic histories and almost daily assaults on our dignity, and we are told to get over it”. She propounds
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The last, and potentially most difficult, of the 6 E’s is to Embrace. This refers to embracing the challenges that come with living at a time when “racism is a significant threat to public health” according to the AMA. Embracing can be difficult because it accepts the notion that racism is still a glaring issue in key areas of society. As a result of this disparity, African Americans are disproportionately affected by “poverty, mass incarceration, infant mortality, limited health care access, and health-related conditions including heart disease, diabetes, stroke, kidney disease, respiratory illness and HIV”. There are many instances where “unconscious bias, stereotyping, prejudice, and clinical uncertainty that vary depending on patients’ race/ethnicity on the part of the health care providers lead to healthcare inequalities creating poor healthcare outcomes and mistrust in the healthcare system”. Embracing should involve both acceptance of the current systemic predicament that African Americans find themselves in, as well as providing patients with ways to stay positive. Difficulties should be expected, but positive and sustainable change can be reached. To help patients achieve this, they should be reminded of the importance of embracing themselves. The perpetrators of racist acts are wrong. Victims of racial trauma should know that their thoughts, feelings, and existences are valid. We have a responsibility to help our patients embrace the challenges that undoubtedly lie ahead.
A recent ethics opinion from the APA (E.4 and E.5) supports my view that it is unethical to misinform, but it does not go so far as to say it is my duty to challenge any misinformation I come across. I am not required to report colleagues to the licensure boards as I would be if they were impaired on the job. I can report them; however, I have no requirement to do so. I do not have a legal duty to report misinformation as I do to report physical or sexual abuse. But the consequence of not reporting could be death for thousands. I do not challenge patients or staff who have decided against taking the COVID vaccine. Instead, I recognize that if I have a good relationship with them, I can give them information, while qualifying that whether or not they take the vaccine is not my decision. This is what we do in psychotherapy – one would not push a view upon patients who have taken entrenched positions, but would wait until the messages could be effectively received. Clearly, the messages must be true. I believe my job as a psychiatrist is to craft a message that can be received by individual patients. It is very challenging work for me. Recently, I had an experience with a person who was having weekly nasal swabs and would not take the vaccine, allegedly due to an egg allergy. He was complaining to me. I took a deep breath and asked if I could give him information or if that would be offensive to him. He said, “Not from you”. I mentioned that the Johnson and Johnson vaccine involves egg, while the others are produced from amniotic fluid and from healthy babies (not aborted ones). I noted that sensitivity to vaccines for him as an individual was there, regardless of whether they were produced from eggs. I specifically said it was not my decision. I had waited until he had mentioned his frustration with the swabbing. “Fruit gets ripe”, I like to say. He heard this message, specifically because I was not violating his autonomy. I have learned from my own painful experiences in life that all conflict is connected with the sense that one’s autonomy is being violated.
Sheila Wise Rowe summarizes what every victim of racial trauma already knows – ‘racial trauma is real”. This inescapable reality is one that African Americans are all too familiar with. Implementing the 6 E’s to Engage, Explore, Empower, Evolve, Empathize, and Embrace with patients who have dealt with racism is a step toward creating lasting positive change for everyone. Should We Challenge Misinformation? How Can We Give Messages So That They Can Be Received? By: Jenny Boyer, MD APA Area V Trustee
I hope we all have the ability to “stay in our own lanes” and not push others so hard that they reject any reasoning or facts at all. I think we all need to work on how to recognize how and when to deliver a message so it can be received, so our patients can make better decisions.
One reason we have increased public health misinformation is that some people gain financial and political power from it. Further, there is no accountability for media companies or even verbal presenters for causing the deaths of the gullible. It is really “buyer beware”. We have always had misinformation, but the widespread availability of it – without alternative perspectives at the time of presentation – is different. Gullible parties include physicians, patients, and members of the general public. The perpetrators of the misinformation are both intentional – which I believe should be more easily prosecuted as criminal – as well as those who are naive. If criminal and civil accountability is not practically available, then that leaves us with ethics and our own persuasive skills.
Reflections on the COVID-19 Pandemic from the Perspective of a Psychiatric Resident By: Arthur Albert Oliva, MD Psychiatric Resident, University of Louisville At the beginning of the pandemic, I was still in my internship year, serving my month of off-service rotation in Emergency Medicine. There seemed to be a collective
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desire to protect ourselves and each other. Appreciation for healthcare workers on the frontline was just emerging. When I was walking home in scrubs, strangers would approach me with, “Thank you for your service”. It felt akin to fighting a war, all of us banded together against a common enemy.
I have been pleasantly surprised by how many I have convinced to get vaccinated. Several of them even reported that they convinced others within their network to join them. Still, others have remained resistant or doubtful.
I volunteered for “surge backup” if the frontline medical team became sick or flooded with too many patients. Although I was relieved not to be drafted onto the medical frontlines, I felt I should still be doing more.
I hope that having a respectful conversation may allow a different perspective that may be the first step to moving them to accept the vaccine. As I see more and more patients completing their vaccines and boosters, I have hope that we can recapture the initial feelings of collective well-being and concern I saw when the pandemic started.
As the pandemic progressed, psychiatric residents were allowed to use telehealth visits. The initial unity – the sense of common purpose – seemed to dissolve as colleagues and patients became frustrated with pandemic surges and restrictions. This virus not only kills indiscriminately, but has divided us along political and social lines. When vaccines emerged, we expected more universal hope, rather than the dissension that followed. The topic all too frequently was addressed by avoidance. Psychiatric trainees are taught to listen, be nonjudgmental, and respect patient autonomy. But the prevalence of so much misinformation and distortion led me to discuss the vaccine with my patients.
Humor And Psychiatry Sometimes, You Just Have to Laugh By: Shree Vinekar, MD It will not be an exaggeration if we recognize Psychiatry as the most laughed-at specialty. There are thousands of jokes and cartoons about it, but many of us decide to choose it anyhow. The population we serve has so much misery and faces tragedies every day with disability and death. Working with this population and attempting to alleviate their suffering, takes a toll on psychiatrists manifested in burnout, early retirements, and even increased rates of suicides (ranked 2 nd to Ophthalmology). Given such suffering of people afflicted with psychiatric disorders and the heavy burdens carried by the psychiatrists in caring for them, it is almost callous for us to laugh. But we have to.
Vaccine hesitancy has been a pervasive issue, especially in southern states and rural areas and inner cities. I have learned that many patients struggle with an inability to reconcile their own internal perception of reality with the reality that surrounds them. I see this in anxiety patients, where they may overplay the risks of a specific fear or phobia, as well as in schizophrenic patients. The skepticism and uncertainty we see when patients consider taking a potentially life-saving vaccine is conceptually not that different. It is not that unusual for us to be the only medical providers our patients see. We have to use our experience and our knowledge to understand and help our patients on this issue of personal and public safety. Talking to a vaccine-hesitant patient can be both tense and aggravating, yet it is not that different than having a discussion with a patient who has a substance use disorder about the benefits of sobriety or a patient with chronic psychosis about the utility of a longacting injectable.
It can be postulated that a sense of humor is a major coping strategy of psychiatrists. Laughter may be one of the best “medicines” for helping us survive. Possibly, Psychiatry is the only specialty where the doctor and patient can keep laughing together for years, and there is more fun and humor in our practice than in any other specialty. A few personal examples come to mind. When I landed at the New York airport in 1969 I became a laughingstock in the customs area when I declared I was going to Oklahoma. They depicted it as cowboy country, where there were gunfights every day. When they heard I was going to train to become a psychiatrist, there was another wave of laughter. Later, I found out I was the first Indian physician to be appointed as a Resident in the department.
My decision to become a “vaccine ambassador” has given me an active role in this war against COVID. I have made special efforts to talk to patients about their vaccine status. I try to use an open tone and a motivational interviewing approach. I seek their permission to initiate a conversation, I listen to their concerns about the vaccine, and I gently emphasize COVID risks. I discuss misconceptions and harm-reduction strategies. They may chafe if I tried to be forceful or authoritarian, which would harden their resistance to vaccination. I have learned to emphasize their autonomy and my belief that they can make the best decision for themselves and their loved ones, while providing them with the most accurate health information.
The Chair, Dr. Jolly West, had a reputation for having killed an Indian elephant in the Oklahoma City Zoo. He and the APA could never live it down, but everyone took this in stride – just like the elephant ignores all the barking dogs when taking a stroll in the villages. The poor elephant had died in the mid-‘60s when Jolly
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experimented on him by administering a heavy dose of LSD to explore if it would induce a psychosis similar to “mast“ (pronounced “musth”). The poor elephant collapsed like an accordion in 5 minutes. It made the news that a psychiatrist had killed an elephant in the Oklahoma City Zoo.
year-old Louis the XIII cognac. It was a practical joke he had played on me for carrying the tale from the Indian elephants to the Oklahoma psychiatrists. Many years ago, I received a frantic phone call, telling me there was a guest at the entrance of that restaurant with his horse, urging the horse to select his favorite items on the menu. “Can you do something for us?” I had to politely decline, saying there the law did not cover a situation such as this. An hour later, I received another, saying the gentleman had brought the horse inside the restaurant and it was walking through the aisles. The same party called 30 minutes later and said he was now trespassing into an arena where he is showing his horse to the audience. “Can you do something? He is a prominent citizen and means no harm to anyone. He is gregarious, sociable and is not aggressive, he just wants to show his horse.” An hour later, he was parading his horse through the town streets by holding on to the reins so that it was walking next to the driver’s window. By now, everyone was almost sure we were dealing with an individual who had bipolar disorder. Soon, the caller said he was now raging and was threatening to set the neighbor’s bales of hay on fire. “Yes, now you can arrange to bring him to the ER, and he can be hospitalized,” I told them.
I had the good fortune of inviting Jolly as a guest speaker several times after he left the department to become the Chair at UCLA. He had a great sense of humor, and he could laugh for hours with his colleagues. His secretary was prompted to ask me when I called to invite him, “Are you still driving the VW beetle?” “Dr. West cannot fit into your car, and you must rent a Lincoln town car if you want him to come to Oklahoma City.” By then, he was the most successful chairman in the country, running a department that was training 200 Residents. Jolly was a man of good principles, and actively demonstrated them. In the 1980s he was the first psychiatrist drawing attention to gun violence as an American epidemic. He and Charlton Heston (“Moses” in “The Ten Commandments”) had also walked hand-inhand to the capitol of Oklahoma to demonstrate sympathy and solidarity with the African-Americans asserting their civil rights. Involving the Department of Psychiatry in the political struggle of the black minority was noteworthy, all the more so back in that time. He appointed Chester Pierce, MD, who was instrumental in starting “Sesame Street” for the disadvantaged children, as a Professor. After the Murrah Building bombing in 1995, I remembered Dr. Pierce and felt that Sesame Street or a program like that would be the best medium to educate children regarding race, culture, and diversity. I contacted the Walt Disney organization, but they were not interested. There were weekly colloquia in the department – the very first department of “behavioral sciences” in the US that arranged to meet with multidisciplinary faculty. Jolly would not limit Psychiatry to the DSM or Psychopharmacology; he wanted it to be an integral part of the community and his students and Residents to have a broader perspective. This was to be accomplished by having fun with wine and caviar every Friday evening. Such collegiality and congeniality went hand-in-hand with a great sense of humor. Then, a swimming pool in the faculty house was built where everyone could mingle. The day it was first filled with water, Jolly was so overjoyed that he jumped into the pool fully clothed!
At 10 p.m. I then received a very polite and jovial gentleman in overalls who was pulling a paper from his pocket, saying he was offered $1 million dollars for his horse by a rancher from Mississippi, and he must finalize the deal the next day. I decided to call his wife and also the rancher from Mississippi. That man said, “This man you have in front of you does have something wrong with him in your department, but he surely has a dandy horse and I want to buy him.” I said, “I cannot release him to go home” (he was on an “emergency hold” because he was an imminent danger to others). With his wife’s permission I gave her telephone number to him. Next day, the horse was headed to a ranch in Mississippi, as the patient’s wife also found the offer too good to decline. The patient, now treated with lithium, was followed in my office at regular intervals for the next 20 years. His wife and daughter would periodically become fearful of his manic behaviors. When he was in his late 70’s, after he had divorced his wife and had a younger woman move into his farm house, he was missing his appointments and was not compliant with treatment. He developed cirrhosis of the liver and ascites. He regretted selling that horse to the rancher, whom he thought had cheated him on the price. His daughter said, “He is refusing to come see you because you stole Buck from him.” When he developed dementia, I became a horse thief in his eyes!
So, I introduced him to the audience when I was the Chief of Staff of a small psychiatric hospital. I told them that I had heard about him long before I had come to Oklahoma City. The elephants in India had heard his reputation and had cautioned me to be beware of him because he had killed one of their brothers. The audience laughed, and he took it in stride. That evening we dined together with the attending staff psychiatrists and the hospital administration at a prestigious restaurant. He was no sooner gone than I received a bill for $900 for the wine I had purportedly served to our guests. It had included 100-
Another story is about how many doctors it took to diagnose and treat what appeared to be trazodoneinduced priapism in a geriatric psychiatric inpatient unit. Every psychiatrist knows priapism can be a rare side effect of trazodone. However, when it occurs, it is a medical emergency and the patient needs to go to an ER. I received a frantic call from a nurse informing me that one
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of my octogenarian patients had had an erection for a couple of hours. My natural response was to tell her to send him to the hospital emergency room. I was covering for my colleague in another hospital nearly 60 minutes away and it would be impractical for me to spend three hours to examine him when I could not give any help. An hour later I received a call saying the internal medicine consultant had seen this patient and agreed he needed to be transferred to the ER. However, he could not be moved out of the geropsychiatry unit unless he was discharged (and would be readmitted once priapism was resolved.) The nurse refused to discharge the patient on my verbal order and insisted it needed to be done on the computer, so I had to personally go there. By the time the medical director appeared on the scene, the patient had been examined by the internist and they decided to call the urology consultant. The director of nursing insisted that the rule of not sending a patient from a geriatric psychiatric unit to the ER without him being discharged – under any circumstances – needed to be followed. This rule was treated as if it was mandated by the federal government. Fortunately, the patient was not in pain. I knew trazodone was a medication he used when home and was well-tolerated according to his admission history. By the time I got there, the urologist had examined him and had said that trazodone-induced erection could be considered harmless if it is resolved within 12 hours. He had used a needle to relieve the erection, I was told. In the process he discovered that this “demented” patient had long ago received an inflatable penile implant. He had inflated it but had forgotten to deflate it because of his memory impairment. A small scar in the suprapubic region would have told the story. The hospital did not get paid for his treatment, as his medical problems were not covered under the “mental health carve-out.” The patient, of course, knew nothing about what had transpired and how many nurses, administrators and doctors had been shaken up by the little pumping balloon!
A Public Health Emergency (PHE) was declared in January, 2020, because of COVID-19. Subsequently, medical services were allowed to be provided by telehealth, both audio and audio/visual. The initial utilization rates for all tele-health increased substantially at that time. Utilization quickly declined for general tele-health and other specialties, but it has remained high for telepsychiatric services. These have been available for some time, but the public health emergency significantly spurred regulatory loosening, so that “providers” made more use of them. Now, it seems that many providers are comfortable providing care by tele-psychiatry and that patients are comfortable getting their care this way. A significant change was that patients could be seen in their “home”, which is more broadly defined than just their house. Care in this way has been allowed under the PHE. The Final Rule for 2022 is written with the expectation that the PHE will some time expire. (It was most recently renewed in October, 2020). Usually, the Final Rule becomes effective on January 1. Most of the changes in the Final Rule for 2022, however, only become effective when the PHE expires and the specific date for that remains unknown. Some of the changes may actually be postponed for the whole calendar year. Tele-psychiatry has an “originating site”, which is where the patient is located, and the “distant site”, which is where the psychiatrist is located. If/when the Final Rule for 2022 becomes effective, it will recognize and reimburse for tele-psychiatry. It continues to allow “home” as an “originating site”. While encouraging audio/visual connection, there are provisions for special circumstances where audio-only will be reimbursed. So, that is an improvement from how it was before the emergency. There are, however, more limitations. For example, geographic limitations resume. For patients seen in the new “home” originating site there will be a new requirement. They will have to be seen face-to-face within 6 months of their initial tele-psychiatric visit and thereafter at 12-month intervals. As usual, there are exceptions for situations where patients have been seen by psychiatrists within your “associated groups”. There are also exceptions to the face-to-face expectations. Other special considerations include Substance Use Disorders, which seem to have more lax requirements, as well as the requirements of the Haight Act, which have also been suspended.
The CMS Final Rule 2022 Where It Stands Now By: Ronald Burd, MD I am a psychiatrist, working in Minnesota with a largely insured patient population. My current practice is 25% in person, 25% by remote-connect to other clinic sites across MN and ND and 50% to other sites (for example, to where the patient is at “home” by tele-psychiatry platforms). The following is based on my reading of the CMS “Final Rule” and discussion with my clinic billing staff and the APA staff. I have tried to reach CMS, but they have not returned my calls nor responded to my e-mail. This summary of my conclusions about the current situation should not be taken as guidance, but rather as a template to inform your reading of the Final Rule and subsequent discussion with your own coding/billing staff and “payers”.
The Final Rule is expected to be the most expansive in its changes after the emergency passes. Other payers, like insurance companies, are likely to be more restrictive. You may wish to lobby both your local payers and state governments to keep these expectations as liberal as possible. APA is working to answer our questions and to lobby with CMS on our behalf. Each
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psychiatrist will need to be aware of how the above changes unfold and how payers will follow them when paying us for the care we provide to our patients.
We also helped organize stakeholder meetings on juvenile justice matters, correctional and prison reform and violence prevention, and re-entry services for exoffenders – including mental health and substance use treatment. During the pandemic, we have been meeting virtually. We have talked about the mental health effects of the pandemic and the importance of telehealth for our patients and ways to expand broadband and telehealth services to rural communities and underserved areas. He subsequently introduced the Computer and Internet Access Act of 2021, which provides a comprehensive plan to expand broadband and internet services and to help create equity in certain communities. It would also provide tax credits for computer and education costs to some people.
Influencing Decision-Making in Congress By: Kenneth Busch, MD At the heart of government is the concept that public policy is made for the common good. How do physicians choose among different kinds of lobbying strategies to influence policy and legislation on Capitol Hill? How can we play an important role in the political process and make strategic moves to advance our priorities in Congress?
This kind of networking has led to other opportunities, such as participating with Speaker Nancy Pelosi and the Congressman a few months ago in Chicago, where we heard about the President's message of fairness, equity and justice for all.
Neither our Representatives nor our professional groups establish policy decisions in a vacuum. Members of Congress do not always understand the specific pieces of legislation. They are eager to learn about the technical information as it relates to certain bills and policy matters and important to constituents in their districts. This gives us an opportunity to see that laws are passed that help our patients and the populations we serve.
At the meeting in November, Congressman Davis briefed us on the Build Back Better Act and compared it to the New Deal, Great Society and Affordable Care Act. He emphasized that the bill represents landmark legislation to provide greater opportunity for working class people to pursue the American dream and to help eliminate poverty and racial injustice.
Such is my experience serving as Chair of the Mental Health Advisory Committee for Congressman Danny K. Davis (D-IL), who has served for 26 years from the 7th district in Illinois. This includes the downtown area and Magnificent Mile in Chicago as well as parts of the Western suburbs. The district is home to several medical schools and many hospitals.
I have learned there is a direct relationship between advocacy and its effect on policy outcomes. Some studies show a direct correlation between the amount of time devoted to advocacy and the probability that bills will get passed. Legislators really do want to hear from their constituents and their constituents want to meet with them. It is important for all of us to engage in the political process. Serving on an Advisory Committee with our Member of Congress is an excellent way to start.
He set up the Mental Health Advisory Committee several years ago. I recall approaching him at an APA Advocacy Day event on Capitol Hill. After it was organized, my colleagues and I started meeting with him on a regular basis in Chicago to discuss specific legislation and policy issues in Congress. One of our early contributions was to work with him on drafting the Second Chance Act, which was later signed into law. This authorized grants to government agencies and nonprofit organizations to provide services such as substance use treatment, that help reduce recidivism.
Good News: No Aluminum is in Current COVID-19 Vaccines By: Steven Lippmann, M.D. Many people all over the world are refusing vaccinations. A significant percentage of our population are “vaxrefusers”; this dangerously applies not just to current COVID-19 preventive shots, but has been a problem with measles and other immunization refusers. Besides arguments like, “I do not trust the government”, there are some specific concerns about genetic modification, fetal tissue, mercury, and other contents, like of aluminum. An adjuvant to augment efficacy for some vaccines, aluminum has been present in certain-but-not-all vaccines.
We began to arrange site visits for him at various hospitals and health care facilities, such as the Rehabilitation Institute of Chicago and community mental health centers. We accompanied him to the venues and participated with staff in the planning and follow up of the events. We participated on several panels at his town hall meetings. Topics we talked about included parity implementation and access to care, as well as ways to reduce stigma.
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Good news: No currently administered and/or considered coronavirus vaccines in this country contain aluminum. Great.
individual. Without this blockade, angiotensin-converting enzyme-2 facilitates the virus being able to penetrate the cell wall, leading to cell death. REGEN-COV is the brand name of two monoclonal antibodies made by the Regeneron company. They selected a dual antibody approach to initiate more powerful immunity against coronaviruses, especially if new virus variants appear. These “casirivimab” and “imdevimab” proteins rapidly block SARS-Co-V-2 cell entry. The protection is a form of transient, passive immunity. Other monoclonal antibodies are under investigation and/or in production.
Why is this an issue for us? Most physicians encourage vaccination coverage. Yet, there are some unsettled concerns that aluminum toxicity might be ideologically related to neurodegenerative disorders like dementia, parkinsonism, and autism. Such associations are not proven; however, this issue is not fully resolved. Without conclusive answers, no consistently researched connection is documented. Even if there is some association, it might only be true for a specific, small subset of individuals who retain and/or deposit aluminum in their brains. Back to the good news.
An Emergency Use Authorization for prescribing casirivimab and imdevimab has been approved. The drug is administered parenterally. For Medicare or Medicaid recipients, it is free. It is only indicated very early in potential COVID-19 disease (NOT late in the course of illness) and only to patients age 12 or older and weighing at least 88 pounds. It is not recommended for hospitalized patients or those receiving oxygen, and not for others with comorbidities that already mandate supplemental oxygenation. They can also be prescribed to individuals who have been exposed and who have positive SARS-CoV-2 testing results and have various comorbidities that confer high risk. It is also now prescribed for those persons who are elderly, and/or obese, after they have been exposed. Medication allergies and/or side effects are reportedly infrequent.
Pfizer, Moderna, Johnson & Johnson, and AstraZeneca vaccines contain no aluminum. They are also without mercury or fetal tissue. Public health and medical personnel are trying to suppress COVID-19. The absence of aluminum in these vaccines is a fortunate benefit. One less reason to remain unvaccinated. One less worry. Monoclonal Antibodies Casirivimab and Imdevimab By Aya Allam, M.D., University of Menoufia Faculty, Egypt & Steven Lippmann, M.D. We are saturated with news about coronavirus infections, vaccinations, and monoclonal antibody treatments. There is uncertainty about some of this; however, one certainty is that the most cost-effective, constructive way to end this pandemic is by getting our population highly vaccinated. Post-infection immunity helps, as well.
These antibodies are not a substitute for vaccination, but it can be effective and safe when properly used.
COVID-19 is particularly dangerous in older and/or obese people and anyone with any comorbidities that impair immunity. Symptoms are usually mild, but vulnerable individuals sometimes require emergency hospitalization and/or intensive care intubation with oxygen supplementation. A high virus load can create a hyperactive immune response that can yield multiple organ failures, especially to the lungs – hypoxemia and/or hypoxia that can be deadly.
What is the Federal Drug Administration (FDA) thinking? In June 2021, it granted an Accelerated Approval for aducanumab for early Alzheimer’s disease. The news was received with great anticipation. There have been no drugs that successfully treat cognitive decline and/or mitigate its ravages. Immediately, however, controversy emerged. The efficacy, safety, and cost of aducanumab immediately came under scrutiny. At this time, physicians still have limited access to beneficial therapies to counter the cognitive decline of Alzheimer’s disease. Patients continue to suffer. But this recent FDA decision, so widely reported, might also have provided false hope to people with Alzheimer’s disease and their families.
ADUCANUMAB: Risk-to-Benefit in Alzheimer’s and Trust in the FDA By: Aya Allam, M.D. and Steven Lippmann, M.D.
Monoclonal antibodies are proteins made in laboratories to match the spike protein antigen of this coronavirus (the part that penetrates human cells following exposure, yielding potential pathology). By simulating the virus’ spike protein, they block its entry into human cells; that action facilitates immunity to protect the infected
Research began years ago to find substances that would diminish beta amyloid in the brain and would mitigate cognitive decline. This has been the approach, even
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though a direct etiologic relationship between amyloid and Alzheimer’s dementia is not established (nor is dissipating plaque deposits clearly documented to improve mentation). Investigations focused on several pharmaceuticals, including aducanumab, a monoclonal antibody that diminishes beta-amyloid deposition.
new monoclonal antibody coronavirus interventions. This could harm our over-all health and prove to be bad for us all. Is Ivermectin Really A Good Idea? By Gurpreet Singh Guliani, M.D. & Steven Lippmann, M.D.
In March 2019, an aducanumab investigation was said to be stopped because of questionable merit. Later, the manufacturer reported that a recalculation of the data, at a higher 10 mg dosage, revealed that the drug did diminish the signs and symptoms of clinical dementia and that it also decreased parenchymal amyloid plaque quantities. Another study showed no advantage beyond that of a control group.
What is going on with ivermectin these days? Your patients, colleagues, and you yourself might be wondering. Ivermectin is approved for prescribing in a cream format for treating humans with scabies and/or in tablets for some parasitic infections; some physicians regularly prescribe it. It is also available in veterinary medicine for eliminating parasites. Human and animal dosing recommendations are not the same. Additionally, some of the animal pharmaceuticals contain ingredients that are not approved for humans.
In late 2020, the FDA’s advisory board voted 10-to-1 against approving it. Nevertheless, in June 2021, the FDA conferred an Accelerated Approval pathway on it. It mandated that the manufacturer continue to conduct research to establish the true safety and risk-to-benefit ratio of prescribing it to patients with Alzheimer’s disease. In the meantime, it is available for use. Political and social pressure on FDA to approve the drug by various Alzheimer and geriatric advocacy groups or organizations might be part of the cause behind their action. Of course, everybody has been wishing for a way to repair diminishing brainpower. Surely, a desire to be helpful was part of the reasoning. Who knows how they actually reached their decision? In the meantime, there is considerable bad feeling.
Nevertheless, it has become a hot-selling drug for treating humans these days – prophylactically and for treating people with suspected and/or confirmed coronavirus COVID-19. It has not been approved for these indications. Is this wise? Ivermectin is well absorbed and has good bioavailability. Metabolized by the liver and excreted in feces and urine, it has a half-life of under one day. As an antiparasitic agent, it blocks glutamate-gated chloride channel closures in invertebrates. At high level concentrations, it also affects GABA channels. Blood-brain barrier penetration is usually not high; nevertheless, cases of toxicity are being reported. It is dangerous to humans in high doses and can interact with some other pharmaceuticals. Side effects include nausea, vomiting, diarrhea, hypotension, and significant neuropsychiatric morbidities such as sedation, confusion, encephalopathy, coma, and/or seizures. Overdosing can result in death.
Administering aducanumab also can induce significant problems. Up to nearly 40% of subjects evidenced edema with swelling of the brain and/or micro-hemorrhage, with a potential for subsequent superficial siderosis (by hemosiderin deposition), and other less serious side effects. Thus, it can cause significant dangers while its effectiveness is still questioned. It is indicated only in early, less severe dementias. No prescreening to document brain beta-amyloid deposition is required. In addition, it allegedly costs about $56,000 a year and must be intravenously administered in a medical facility – adding additional expense. The packaging calls for a magnetic resonance imaging scan of the head to have been performed before the drug is started and twice during the active administration period. Currently, it is not widely covered by government or private insurance plans, making it primarily available only to a select population.
Ivermectin can inhibit SARS-CoV-2 replication in vitro. However, controlled trials of treatment for patients with SARS-CoV-2 infection have shown little, if any, benefit. The NIH makes no recommendation for or against ivermectin interventions for persons infected with SARSCoV-2. Some American physicians are frequently prescribing ivermectin currently, off-label, and claim success at attenuating the severity of COVID-19 disease. Perhaps ivermectin has efficacy, but these accounts are not research-grade data. News articles report individuals who have sued for court orders to force its administration – against a treating clinician’s judgment. Some individuals who refuse approved vaccines – now already safely administered to hundreds of millions of people – are demanding it.
How could the FDA so easily approve this rather questionable, very expensive, and somewhat dangerous drug, while taking longer to approve COVID-19 vaccinations that have been investigated and administered successfully to millions of people? Confidence in the FDA, its approval process, and the Accelerated Approval method has been diminished. Loss of trust in the FDA may further increase coronavirus vaccine hesitancy or refusals – maybe even so for the
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Self-administration is dangerous. Dosing instructions for humans are not always clear. Some veterinary grade versions are highly concentrated, and the dosing recommendations are not consistently calibrated for humans. There is no regulatory sanction for its use in coronavirus infections, but if it is used in people, it should only be prescribed by a doctor familiar with it.
diminished sense of smell, taste, vision, and/or pain, and about 13% complained of depression and/or anxiety. Dizziness, headaches, ataxia, seizures, and/or cerebrovascular issues were documented among 10% of subjects studied. Even for patients who never required hospitalization, the incidence and risk of neuropsychiatric diagnoses have risen. Lower quality of life is often observed. Complications usually vary according to the severity of the infection.
Who knows what the final story will be? What Neuropsychiatric Issues Come With COVID-19? By: Amal Mumtaz, MD & Steven Lippmann, MD
We need to find out more, both about the infection and its variants, and also about what happens after people “recover”.
COVID-19, spreading throughout the world, has caused many fatalities. Several countries are still facing emergent public health crises. Although rising vaccination rates in some places have decreased the incidence of hospitalizations and somewhat helped people to return to their everyday lives, the pandemic still might be here for a long time.
COVID-19 and Substance Abuse By: Srija Chowdary Vanka, MBBS & Steven Lippmann, M.D. The rise in substance use disorder (SUD) diagnoses and overdose deaths over the last two years appears to be partly attributed to the stress of the COVID-19 pandemic.
Neuropsychiatric complications of COVID-19 illnesses remain major concerns. A review of 34 studies with followup for three months post-COVID-19, documented several common mental health problems. The range varies: from anxiety (7% - 63%) and depression (4% - 31%) to posttraumatic stress disorder (12% - 47%). Fatigue, pain, anxiety, and/or depression were common to many patients, especially in those who needed the most intensive levels of care. The months immediately postCOVID-19 showed a markedly decreased quality of life. Nearly one third of former inpatients with COVID-19 experienced cognitive impairment, depression, and/or anxiety that lasted for months. These were most frequent among those with previously severe illness. About 25% of them reported central nervous system manifestations of dizziness, headaches, cognitive decline, ataxia, seizures, and/or acute cerebrovascular disease.
There are many reasons why people are abusing drugs more now. The tension and anxiety induced by social isolation seem to be major factors. Financial strain, isolation, unemployment, being out of school, fear of infection, and grief about the loss of loved ones are some of the issues. Difficulty in accessing medical care is another factor, with some clinics requiring direct, inperson patient visits and others offering only telemedicine. Quarantining has been especially difficult for people with SUD. Government-supplied relief money has provided more cash for potential substance usage. Pandemic restrictions have limited the access to treatment – even peer-support groups. The Center for Disease Control and Prevention (CDC) reported more than 96,000 drug overdose deaths from March 2020 to March 2021, which is nearly 30% more than the year before. These fatalities now well-exceed 100,000. (Though this number is based on provisional statistics, variation with final data is typically small.) Opioids accounted for the highest number of casualties; death induced by fentanyl predominates. By May 2021, there was also a 31% increase in alcohol consumption. Patients with SUDs are at a higher risk of dying from COVID-19, especially those with pre-existing comorbidities and chemical dependencies that induce additional vulnerabilities.
Early in the pandemic we saw an increase in neurological and psychiatric diagnoses, even among outpatients. The following were the rates of early neuropsychiatric diagnoses: nearly ½ included any sequela, about 1/3 experienced mood, anxiety, and/or psychotic conditions, just under 10% abused drugs or complained of insomnia, 3% evidenced an ischemic stroke or nerve, nerve root, or plexus disorder, 1% had an intracranial hemorrhage, and few were documented with dementia, encephalitis, parkinsonism, Guillain-Barré syndrome, and/or myoneural junction or muscle diseases.
It would help if we could convince most of our population to be fully vaccinated and “boosted”. The CDC has now expanded its recommendation of booster-shots to all adults. The initial recommendation, which was targeted towards high-risk populations, included people with SUD, thus highlighting their heightened susceptibility.
There are also long-term clinical issues for people after they recover. These are often persistent and are referred to as “long-COVID”, “post-COVID syndrome”, “long-haul COVID”, or “long-haulers.” These include: 44% evidenced inattentiveness, 39% had poor memory, 22% reported
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Earlier in the pandemic, most health care systems were not prepared. Medical care delivery is now improving: higher vaccination rates, more direct clinic access, telemedicine, reopening of inpatient hospital beds, and an increasing number of antiviral pharmacotherapies and monoclonal antibody applications. People with SUD’s are returning to peer-support group meetings. Also, the advent of telemedicine directed specifically towards behavioral health issues made care more available. Insurance companies and government agencies are recognizing this need. For example, the Substance Abuse and Mental Health Services Administration and Drug Enforcement Agency are allowing the prescribing of buprenorphine to new and/or existing patients via telephone contacts, without requiring in-person medical evaluation or via formal telemedicine visits.
Overlapping presentations include mood fluctuations with anger, irritability, depression, variation in energy levels and/or sleep, poor self-esteem, hopelessness, worthlessness, and/or various aspects of suicidal thinking. Impulsivity with risky behaviors in at least two areas (i.e., sex, substance use, reckless driving, and/or binge eating) is observed in people suffering the personality disorder, whereas shopping sprees, foolish business decisions, and/or sexual indiscretions occur frequently in individuals with bipolar disorders. Impulsivity during BPD is usually pervasively chronic, whereas in bipolar disorder it is often more intermittent. Quick changes in mood, triggered by psychosocial or environmental factors, frequently last only hours for individuals with BPD. However, in patients with bipolar disorder they typically might last for days during hypomania, a week or so in the course of mania, and still longer throughout a depressive episode.
Society still stigmatizes the poor choices and/or bad judgment that often come from SUD. This adds to social marginalization and difficulty in access to therapeutic services. The pandemic has worsened this problem. However, many people now understand that alterations in the brain play a role in the development of addictions. Healthcare professionals are increasingly aware of these problems and need to work to increase the care we can still deliver.
The distinguishing factors suggesting BPD include unstable relationships with extreme interpersonal hypersensitivity, associated with identity crisis and poor self-esteem. Attention-seeking behaviors with compromised social and parent/child relationships are commonly noted. Patients with bipolar disorders in a manic and/or hypomanic episode often evidence elevated self-esteem, grandiosity-driven risky behaviors, pleasureseeking episodes, flight of ideas, and pressured speech.
Borderline Personality vs Bipolar Disorder By: Muruga Loganathan, MD & Steven Lippmann, MD Young adults and adolescents are frequently hospitalized with mood lability, suicidality, and/or self-injurious behaviors. Emergency department and inpatient admissions, at high health care utilization and cost, have escalated for nonsuicidal, self-harm issues. Differentiating borderline personality disorder (BPD) from bipolar disorder in such individuals is a challenge. These conditions have overlapping symptoms of mood fluctuation, impulsivity, risk for or harmful behaviors, and/or suicidality. About 10% of patients with a borderline personality diagnosis are also sometimes labeled with bipolar type I or type II disorders.
The Mood Disorder Questionnaire (MDQ) helps screen for bipolar disorders and the McLean Screening Instrument assesses borderline personality disorders. With the MDQ, a symptom triad of elevated mood, increased goal-directed activities, and mood fluctuations predicts a bipolar diagnosis with a sensitivity of near 89% and specificity at 84%. The Mclean Instrument, with an 81-90% sensitivity and 85-93% specificity, is a good evaluative tool for helping to diagnose the personality disorder. Structured clinical and diagnostic interviews, especially the Diagnostic Interview for Borderline Revised Scale, are considered the best means for diagnosing borderline personality disorder. The self-report prevalence rate measures are usually higher than for clinician-administered interviews; nevertheless, unstructured clinical interviews are less reliable at detecting of personality disorders.
Distinguishing between the two is particularly important because the interventions are different. For example: incorrectly treating patients with borderline personality with pharmacotherapy increases their risk of obesity, hyperlipidemia, and/or diabetes. Someone with undiagnosed bipolar disorder who is only receiving psychotherapy may experience mood swings – resulting in dysfunction, hospitalizations, and decisions with negative consequences. A recent proposal to categorize the ultra-rapid cycling moods of a person with a bipolar diagnosis could make it more difficult to distinguish between the two.
Dialectical behavioral therapy (DBT) is the standard treatment for BPD; yet, there are challenges in finding therapists administering this modality and patients have to make a significant time commitment. The General Psychiatric Management (GPM) program advocates that prescribing physicians practice this type of therapy. It focuses on the goal of building a meaningful life rather than just reducing self-injurious behaviors. It provides hopeful/supportive diagnostic disclosures, psychoeducation, and suicidality/self-harm management. If the patient’s bipolar manifestations are severe, a mood stabilizer and/or an antipsychotic might be indicated.
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GPM training for medical students, residents, and other healthcare providers may help.
Table: DIFFERENTIATING BORDERLINE PERSONALITY FROM BIPOLAR DISORDERS
So would more accurate diagnosing!
*Paris J. Suicidality in Borderline Personality Disorder. Medicina (Kaunas). 2019; 28;55(6):{223}:1-6
Case Vignette: The patient is a 15-year-old female who was living with her mother and 13-year-old brother and was visiting her father on weekends. She was a sophomore student whose grades were declining. She used to get admitted every 1-2 months for suicidal attempts and self-injurious behaviors. She was fighting with her mother, was often depressed, and was irritable, with intermittent mood swings. She had poor sleep, with nightmares, and occasionally heard hallucinations say, “Go die!”. She skipped meals in the morning and did binge-eating at night. She was having panic attacks at least once a week. Mom stated she was associated with a counterproductive group, was drinking, and was sexually active. Diagnosed with bipolar disorder, she was prescribed aripiprazole, fluoxetine, lamotrigine, and hydroxyzine, but was noncompliant with medications because of weight gain. On her sixth admission in the past year, she was treated for an acetaminophen and hydroxyzine overdose. She was having difficulty relating with her friends, was feeling excluded, and was having brief romantic relationships that led to depressed episodes. Breakups had distressed her, so she was cutting herself, and had been overdosing.
** Novick DM, Swartz HA, Frank E. Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence. Bipolar Disorder. 2010;12(1):1-9
During initial admissions, she was treated for major depressive disorder with psychosis and generalized anxiety with panic attacks. Intermittent mood swings, irritability, impulsive drinking, sexual activities, and auditory hallucinations confused her treatment team; they had utilized the diagnosis of bipolar disorder. Various trials of mood stabilizer and antipsychotic drugs were tried in vain. Self-injurious behaviors, irritability, and conflicts in relationships continued. She had interpersonal hypersensitivity, and felt rejected by peers and poorly understood by her parents. She longed for relationships and wanted to please her friends. She had little emotional awareness and low self-esteem. “Borderline personality traits” had been applied to her, instead of a personality disorder diagnosis, because of her youth.
REMDESIVIR: Is It Worthwhile? By: Aya Allum,M.D. & Steven Lippmann, M.D. Remdesivir is a pro-drug antiviral pharmaceutical that came to prominence years ago as a potential medicinal during the Ebola epidemic in Africa. While not very effective for that indication, it yielded valuable research and clinical experience into potential therapies that are now prescribed during this coronavirus, SARS-CoV-2, epidemic.
She was referred for DBT and family therapy and her parents were provided “management training”. She showed interest in understanding herself and wanted to become a psychotherapist. The focus of building a more meaningful life decreased the frequency of hospital admissions. She was readmitted for the 7th time, after 5 months; she processed repressed memories of trauma and made good progress. Self-injurious behaviors have declined, and she now is able to converse more rationally about her problems.
In the human body, remdesivir is converted into an active agent that blocks replication of the virus. This is accomplished by preventing host cell adenosine, amino acid incorporation into viral RNA via inhibiting RNAdependent-RNA polymerase. Remdesivir re-emerged in hopes to become a therapeutic means of combating the respiratory viral disease among COVID-19 sick people. It was proposed to attenuate viral loads, limit lung tissue damage, and shorten the duration of illness. As President,
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Donald Trump received this medication when he contracted COVID-19, even before it had been granted prescribing approval.
In Memoriam
Subsequently, remdesivir received use approval for this indication, by prescription only, under the brand name of Veklury. It is manufactured in a solution or powder form that is constituted into a liquid; then it is slowly infused intravenously while under medical supervision, usually in an infusion center or hospital-type setting. This medicine is indicated early in COVID-19 disease for persons who are over 12 years of age, weigh at least 40 kilograms, but not for anyone hospitalized, oxygen dependent, nor in advanced stages of illness. There are instances of providing remdesivir subcutaneously to people prophylactically following a known recent SARS-CoV-2 contagion exposure.
A TRIBUTE: HAROLD EIST, MD 1938-2021 By: Bruce Hershfield, MD Harold Eist, MD, a past president of APA and longtime friend to many of us, died December 16th at age 83 of complications of hip surgery. He was a major figure in psychiatry. Originally from Edmonton, he attended the University of Alberta and did his psychiatric training at the University of Minnesota and his analytic training at the Washington Psychonalytic Institute. He was director of a mental health clinic for many years, earning it a Gold Medal from the APA and being personally named the Washingtonian of the Year in 1979. A Clinical Professor at Georgetown, he wrote more than 100 articles. For many years he practiced child and adolescent psychiatry and adult psychiatry in Bethesda. Active in psychiatric organizations, he served as President of the APA and was the North American Rep on the World Psychiatric Association board. He served three terms as President of the Washington Psychiatric Society, was an affiliate member of the Maryland Psychiatric Society, and also was active in the Southern Psychiatric Association.
The usual duration of repeated administration varies between 5-to-10 days, dependent on the degree of clinical progress. Kidney function, hepatic enzyme monitoring, and coagulation studies are performed before administration and during treatment. It is not indicated for individuals in renal failure. Known adverse reactions include gastrointestinal complaints, pulmonary dysfunction, and/or abnormally high transaminases levels. Remdesivir evidences little clinical attenuation of mortalities, yet it might shorten recovery times and could limit illness severity in patients with serious COVID-19 infections. Initially, it was hoped to be an effective antiSARS-CoV-2 drug, but recent experience is less convincing. Further investigations are on-going along with debate about its efficacy.
He was particularly important in warning us about how business practices could corrupt the ethics of our profession if the two got too closely intertwined. Dr. Brian Crowley, who recently served two terms as the Area 3 Trustee in the APA, commented, “Roger Peele called Harold 'Churchillian' for his frequent warnings about the rise of managed care, with its interference in the doctorpatient relationship and greed in taking money from the healthcare system. One aspect of Harold's activism in organized psychiatry and daily life was his emphatic support of being inclusive, and his antipathy to prejudice of all kinds, including those based on color, gender, sexual orientation, religion, and social position.”
In the meantime, these concerns, high expense, and parenteral administration limit use. Vaccination remains the primary means of protection from serious COVID-19 disease and/or death. There are also several other antiviral medications becoming available and/or granted use approval. Some of these newer drugs have the advantage of being orally administered. In addition, there now also are monoclonal antibody pharmacotherapies that have a different mode of action that helps by attenuating viral host cell-entry. Antiviral and monoclonal antibody treatments can simultaneously be applied advantageously when clinically appropriate.
He also fought hard for many years to protect the privacy of our patients. He was the sort of man who was willing to pay whatever it took for standing up for what is right. Dr. Steve Sharfstein recalls the APA election in 1994 when Harold and he traveled the country and debated no less than a dozen times in various district branches. That year, over 15,000 psychiatrists voted – a record – with Dr. Eist winning the APA presidency by a few hundred votes. Dr. Sharfstein and Dr. Eist bonded over that time when real issues could be discussed and debated. (These days, only a few thousand psychiatrists vote in APA elections.) Dr. Sharfstein commented, “We all shall miss
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Harold’s energy and deep commitment to the profession. I will especially miss his friendship.”
He served as Chair for over 30 years. As Chair, Dan expanded the funding of his department by developing contracts with hospitals around the state. After Katrina devastated New Orleans and temporarily shut down the medical school, the contracts Dan had set up were the only significant sources of cash for the University.
Many of his admirers spoke movingly of how much he had influenced them when they learned of his death. William Thornloe, MD from Georgia captured one aspect of Dr. Eist particularly well: “He was a giant among us. We will all miss his ability to have convictions and to have actions based on those.”
His CV is replete with honors and awards. A few of them include: the Menninger Award of the American College of Physicians, a Presidential Commendation from the APA and Psychiatrist of the Year from the Louisiana Psychiatric Medical Association.
Dr. Jay Scully, former Medical Director of the APA, commented, "Dr. Eist always championed the doctor/patient relationship and was a fierce defender of our profession. "
He was also Chair of the ACGME Residency Review Committee for Psychiatry and President of the Academy of Psychosomatic Medicine. He was active in the American College of Psychiatrists and on the American Board of Psychiatry and Neurology, where he served as a Director for 8 years.
In his remarks on receiving the 2015 Distinguished Alumni Award from the University of Alberta, Dr. Eist said, “We have to try to make it more. My patients inspired me to work hard, to learn and to constantly challenge myself to find more creative ways to help.” He went on in that generous way he had, “My wife, Ann, has been with me for almost 56 years. She is my best friend, loving, nurturing, trustworthy, beautiful, and reliable. She is my alpha and omega – the first and the last, a clearheaded assistant and companion. As Churchill said of Clemmie, ‘We have traveled ceaselessly over endless seas.’”
Dr. Winstead joined the Southern Psychiatric Association in 2006 and was president from 2009 – 2010. The last meeting he attended was in Baltimore in 2016. We were very fortunate to have him as a member of the Resident Research Award Committee until 2018. More than all of the above, he was a beloved teacher and mentor for generations of students, residents and faculty.
Dr. Crowley, who was close to him for more than 50 years, said, “I'd known Harold as a good friend and worked with him in Washington Psychiatric Society and APA matters for so many decades, and those many rich, unforgettable memories temper the real sense of loss.”
My wife, Mary, and I traveled with the Winsteads, and it was always a treat when we were stopped on the street by some young adult who recognized Jenny as his or her beloved first grade teacher at the Newman school, where she taught for many years.
IN MEMORIAM : DANIEL K. WINSTEAD, MD By: Jay Scully, MD
Dan was a gourmet and dining was always an event. Once we were having brunch at Commander’s Palace and the entire Manning family – Archie, Payton, Eli et al – stopped by to pay respects. Another time, at Emeril’s restaurant, Emeril himself came over to our table to visit with Dan, sat for a while and then had every dessert on the menu brought to our table. There are many such stories.
Dan Winstead passed away in August. Jenny, his wife and partner of nearly 50 years, had died a few years earlier after a long course of dementia, and Dan had been living in an assisted living facility.
Even while grieving the loss of his wife, he still had his great sense of humor.
He is survived by their son, Teddy, a gastroenterologist, their daughter, Laura, a child psychiatrist, and three grandchildren.
Dan lived a life full of kindness, brilliance, humor and caring. The world is a lesser place without him.
Dan was originally from Ohio, where he graduated from the University of Cincinnati before attending Vanderbilt Medical School. He then went back to Cincinnati for a psychiatry residency. After serving in the Army in Nuremberg, Germany, he was recruited to Tulane. It did not take him long to rise through the ranks to become Chair of the Department of Psychiatry and Neurology (yes, both) and to be invested as the Robert G Heath Professor of Psychiatry.
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LETTER from the EDITOR: The Rose By: Bruce Hershfield, MD
2022 Spring Reception with PRMS New Orleans, LA
When I was attending the Annual Meeting in October, I could see how our organization is compensating for the pandemic. The quick turnaround from an in-person meeting to a virtual one was impressive.
Mark Your Calendar for our Spring Reception with Professional Risk Management Services, Inc At the Annual APA Meeting Sunday, May 22, 2022 6:00 p.m. to 9:00 a.m. Additional Details Will Be Provided Soon
The SPA leadership deserves a lot of credit, especially because the group that just left office did the job for two years instead of one. Our President, Kea Cassada, and Vice President, Dave Casey, deserve special thanks for their devotion to getting the job done. So do the other officers, members of the Board of Regents, and Chairs of committees. A special recognition should go to Mary Jo Fitz-Gerald and also Mark Wright, for chairing the program committee. Our Executive Director, Janet Bryan, and Alabama’s Meghan Martin also deserve a lot of credit.
2022 Annual Meeting–Baltimore, MD With Maryland Psychiatric Society September 7 – 11, 2022 Royal Sonesta Hotel Baltimore, Maryland
For the first time since we got a seat in the APA Assembly, we are transitioning from one Rep to another (because of term limits). Mark Komrad’s eloquent efforts to warn the Assembly and all Americans about the dangers of euthanasia in our patient population have been very important. He has done an excellent job for us for 7 years – particularly because he was our first Rep, and had to do a lot of it during the pandemic. Mark Wright, who has extensive experience as Kentucky’s Assembly Rep, is switching over to representing us, and I am sure he will do just fine. What was missing from the virtual meeting? The opportunity to see people in person! I did enjoy the virtual party afterwards, but there were only a few attendees. I am delighted that Janet is looking into finding a way for us to virtually see each other and to talk with each other on a quarterly basis. That could do a lot for re-establishing the relationships that used to characterize our meetings, and might be something we would choose to continue even after we start meeting in person again.
2023 Annual Meeting–Huntsville, AL With Alabama Psychiatric Physicians Association October 11 – 14, 2023 The Westin Huntsville, Huntsville, AL
I am looking forward to the spring – Including seeing everyone in person – at our reception at the APA meeting in New Orleans. I do know that just when the daytime seems like it will disappear forever it starts to return. Spring will be here soon. Remember Bette Midler’s rendition of Amanda McBroom’s “The Rose”? “Just remember in the winter Far beneath the bitter snow Lies the seed that with the sun’s love, in the spring becomes the rose.”
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SPA OFFICERS 2021-2022
“SOUTHLANDS” EDITORIAL ADVISORY BOARD
President: David Casey, MD President Elect: Thomas Franklin, MD Vice President: Mary Jo Fitz-Gerald, MD Secretary-Treasurer: Rodney Poling, MD Board of Regents, Chair: Abhinav Saxena, MD Board of Regents, 2nd Year: Lauren Pengrin, DO Board of Regents, 1st Year: Felix Torres, MD APA Assembly Representative: Mark Wright, MD Immediate Past President: Margaret Cassada, MD Executive Director: Janet Bryan
William Greenberg, MD Steven Lippmann, MD Jessica Merkel-Keller, MD Denis J. Milke, MD Editor: Bruce Hershfield, MD Assistant Editor: Janet Bryan
“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)
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