SOUTHLANDS
See You In Chattanooga – and Rock City!
By: MaryJo Fitz-Gerald, MD SPA President
Many of us of a certain age remember long road trips for family vacations. A stop at Stuckey’s was always a treat, with the small diner and lots of goodies to eat, and restrooms and a place to fill up the car tank. Invariably, we’d see barns along the highways. They were large red ones with black roofs. And, of course, many of us pestered our parents until they gave into the requests to “See Rock City.”
If you’ve never had the pleasure of going there – with a view of 7 states – or experiencing Fat Man’s Squeeze, you’ll have time to see the sights while in Chattanooga for the meeting of the Southern Psychiatric Association and Tennessee Psychiatric Association at the Westin Hotel from Sept 11-14, 2024. The theme is “Healthy Minds Through the Life Span.”
Debra Barnett, the Program Committee, and the Executive Councils of both the Southern and the Tennessee Psychiatric Association have developed a wonderful program that includes 15 hours of CME, social events, and even a movie discussion. There is plenty to interest everyone.
Chattanooga is a wonderful place to visit. In addition to Rock City and Lookout Mountain, there are a lovely aquarium, a zoo, and a riverwalk. The SPA met in Chattanooga a few years ago and the aquarium was a big hit. The Chattanooga Choo Choo, of the Glenn Miller song fame, is another local landmark for history buffs.
Chattanooga is a gateway to the Appalachian Mountains and the Great Smoky Mountains National Park. This is probably the most visited national park in the country. If you’re interested in making a detour, the park does require parking passes. The link is here: Fees & Passes - Great Smoky Mountains National Park (U.S. National Park Service) (nps.gov)
I’m hoping to see all of you in Chattanooga for education on “Healthy Minds Through the Life Span,” while we enjoy good times with old and new friends – and earn 15 hours of CME
Chattanooga is Calling
By: Debra Barnett, MD Chair, SPA Program Committee
Have you been to a Southern Psychiatric Association meeting?
If so, then you are already aware of the pertinence of the presentations, and the depth of knowledge of the presenters – and all of this in a pleasant and welcomingambiance. Themeetingthis year features top-notch speakers, and the topics are as relevant as they are diverse. For instance, the “Wellness Panel” includes a discussion by Dr. Gary Weinstein on integrative wellness techniques, and Dr. Dilip Jeste will be presenting to us on wisdom and well-being in positive psychiatry. Some of the topics that address progress in psychiatry include biomarkers and drug development in MDD and the use of digital therapeutics in psychiatry. Also, taking an innovative approach to scientific programs, we have put together a review and panel discussion of the movie “Inherit the Wind”. Released in 1960, it was based on the 1925 trial of a teacher in Tennessee who dared to teach his students about scientific theory, specifically Darwin’s theories of evolution. Attendees can also learn more about history as we examine the Tuskegee Syphilis Study and (in contrast) Vanderbilt University’s inclusion of Cherokee and Chickasaw students in the late 1800’s.
All of this is set for September 11th-14th in Chattanooga, in conjunction with the Tennessee Psychiatric Association, starting with the Welcome Reception on the evening of the 11th You will want to include the Dinner Gala on Saturday night, September 14
After all, with the Southern Psychiatric Association, you may initially come in as a stranger, but you will leave as family.
As a personal side note, I could not help but reminisce about traveling through this area of the South in my youth and seeing the signs inviting travelers to “See Rock City”. Rock City is an attraction on Lookout Mountain with gardens that provides scenic views of 7 states. According to Wikipedia, the owners advertised by painting the sides and roofs of 900 barns in 19 states by 1969 so these were seen on the highways and by-ways throughout the South.
Executive Director Update
By: Janet Bryan
It’s mid-summer and our Annual Meeting with the Tennessee Psychiatric Association is quickly approaching. The Westin Hotel room block ends on August 12, and there are limited rooms available. On Friday evening, September 13, there is a social event at Mac Avenue. It is sponsored by PRMS and is designed as an opportunity
for networking and unwinding from the day’s sessions as you enjoy an Italian buffet dinner.
Please share the Program Agenda and Registration Form at the end of the newsletter with your colleagues and encourage them to attend.
There is a Business Meeting scheduled on Friday afternoon, September 13 One of the agenda items will be the voting of new Council positions – below is the Slate of Officers:
President: Rodney Poling, MD
President Elect: Raymond Kotwicki, MD
Vice President Mark Wright, MD
Secretary/Treasurer: Jenny Boyer, MD
Board of Regents Chair: Chasity Torrence, MD
Board of Regents 2nd Year Rahn Bailey, MD
Board of Regents 1st Year Phil Scurria, MD
APA Assembly Rep: Felix Torres, MD
Immediate Past President Mary Jo Fitz-Gerald MD
Please welcome our newest members
• Fiona Doherty, MD
• Laura Dunn, MD
• Daphne Glindmeyer, MD
• Alden Littlewood, MD
• Monica Rettenmier, MD
• Audrey Summers, MD
• Anupama Yedla, MD
If you know someone who would enjoy being part of the Southern Psychiatric Association family, connect them with me so I can inform them about the application process. Here is a link to the membership application: Join Southern Psychiatric Association (sopsych.org)
Interview: Ray Kotwicki, MD
May 5, 2024 New York, NY
By: Bruce Hershfield, MD
Q: “Please tell us about what you are doing these days.”
Dr. K: “I recently started a new position as President and Chief Medical Officer for outpatient services at a national company called Hightop Health. This was after 18 years as CMO at Skyland Trail, which is a residential program. It’s a bit like when a child graduates and goes off to college. I am in the next chapter of my life.
It’s headquartered in Atlanta, but I travel quite a bit. We have some clinics in Texas and northern Florida, and we are expanding into the southeast. I love traveling!”
Q: “Why do you love traveling so much?”
Dr. K: “I love food I’m a bit of a ‘foodie’. I think experiencing a new city through different restaurants and
markets really helps me understand the people, the culture the vibe of a new place. I think it’s very transformative. It makes me a better psychiatrist because a lot of patients, families and communities express emotions through food.”
Q: “Can you tell me one or two places you like in particular?”
Dr. K: “Recently I went to an Asian fusion restaurant here in New York and it was brilliant. Haute cuisine with French sauces and fancy dips, along with Asian ‘street food’. They melded these together phenomenally. My favorite restaurant in Atlanta is named Bacchanalia I like that ‘debauchery’ every once in a while, but I couldn’t do it every day!”
Q: “How did you get involved in Psychiatry?”
Dr. K: “My mother used to say that before I was a psychiatrist I was a ‘real doctor’. I started in Internal Medicine, and I was in an intense program in Boston to do Categorical Medicine. A supervisor told me in a disparaging way, ‘You talk too much to your patients’. He meant I should concentrate less on the context and the geopolitical and the socioeconomic aspects of what was going on with my patients’ health and spend more time trying to figure out how to adjust the insulin dose. It was a primarily Portuguese-speaking patient population in the clinic, and we needed to see 4 patients per hour. And I don’t speak Portuguese! I don’t think it was meant to be a compliment, but I took it as one, in that it suggested I wanted to forge a different kindof therapeutic alliance with my patients – Instead of simply writing a prescription and sending them on their way.”
Q: “That happens a lot to us, I think.”
Dr. K.: “I know quite a few people who have had a similar experience. But as a result of my experience, I feel comfortable with procedures I can start lines and read EKG’s. But now I also have the privilege of listening to the narrative of patients and having the time to develop that bond sometimes over years.”
Q: “Do you treat patients, as well as handle administrative matters?”
Dr. K: “I do. The majority of my work includes administration and supervising other physicians and other healthcare folks. I also teach. I am an Adjunct Professor at Emory and I am on the Resident Selection Committee. Beforethat, I directedmedicalstudent education at Emory for about 8 years. It was not just in Psychiatry. They have a 6-credit per semester class called ‘Becoming a Doctor’. The acronym is ‘BAD’! I taught that class with an internist, and it was extremely gratifying. We got to know all the students personally. We talked about things like how to write a CV and how to network at meetings. Ed Hundtert at Harvard would call that the “implicit curriculum’ of Medicine how you develop as a professional and identify as a physician. It’s an important lesson and it often doesn’t receive as much attention as the traditional didactic curriculum.”
Q: “Did you train at Emory?”
Dr. K: “I did not. I went to undergrad and med school at the University of Wisconsin. In the mid-‘90s they had a program where one could do baccalaureate training in coordination with med school, since they wanted to hasten the development of new physicians because there was such a shortage of them. But I didn’t go along with that; I took the full time. I taught ballroom dance for a semester to make some money, and I studied ethics and went abroad, so I didn’t fulfill the objective of that program. But I learned a lot more about the humanities than I ever thought I would, which is really useful in forging interpersonal relationships.”
Q: “Why did you move from Wisconsin to the South?”
Dr. K: “After finishing my Internal Medicine internship, I was looking for an opportunity to switch into Psychiatry, and Emory had what was then one of only two such ‘fellowships’ an opportunity to finish a Psychiatry residency while getting a Master’s in Public Health. Atlanta is an important city for public health. The American Cancer Society is there and the CDC is there. So I went to the School of Public health and earned an MPH in Public Health Management and Policy. It was extremely useful.
I fell in love with the South. I didn’t expect to live below the Mason Dixon line, but then I said it would be OK for two years while I finish my fellowship. It’s been 23 years!”
Q: “I know you got involved with psychiatric organizations, because, when I met you, at the SPA meeting on Amelia Island, you were the president of the Georgia DB.”
Dr. K: “It was about 7 years ago. It was a great venue. I hope the SPA can partner with the GPPA again in 2026 and go back there.
It’s been a real treat to be a part of the Southern. One of my friends from the GPPA, Theron McLarty, mentioned it to me one time and he sponsored my application and he introduced me to some of the members. I became intrigued with it and joined immediately.
Being a member of the SPA is kind of a ‘special sauce’. The congeniality of the relationships among the members that’s kind of rare anymore. You get the sense the members care about each other and enjoy spending time together.”
Q: “What would you like to see for yourself and the SPA and Psychiatry in the future?”
Dr. K: “I think the Southern would benefit if we could engage the newest graduates in a meaningful way. They could get some of the benefits of the relationships that I have experienced, for themselves. I think the pandemic fundamentally changed the world. People seem to be craving that kind of meaningful interconnection in a way that is palpably different than 4 years ago.
In my own life, I’ve had some experiences that have enabled me to be helpful in program development and in managing organizations. I would like my ‘swan song’ to include me engaging in that on as large a level as possible. Not to create a profit or to set up a conveyor belt of processing patients, but to try to extend what we know of the art and science of Psychiatry to as many as could benefit from it.
I really like the combination of Medicine and Psychology in Psychiatry. Yesterday, the incoming president of the APA talked about his goals of incorporating Lifestyle Medicine into Psychiatry, and Psychiatry into Primary Care. You can conceptualize mental illness as affecting not only thinking and feeling, but also see ‘below the neck” as equally important as “above’ it. I think the future calls for us to focus on ‘whole body health’ so that the idea that physical health and psychiatric health are parts of the whole becomes the common understanding of what it means to be a healthy person.”
Two Ways of Accessing Healthcare A Tale of Two Cities
By: Shree Vinekar, MD
TheUS spends approximately $11,000 per capita each year on healthcare, offering an average life expectancy of 74 years. Many countries like Switzerland and South Korea have far-better-looking life expectancy at much lower cost.
Theparametersusedtoassessqualityofcareandaccessto care are difficult to use if one wants to compare the US with India – a 70-year-old country with a population of 1.4 billion. Although it is the 4th largest economy in the world, it is still a developing country, with many living in poverty.
“India…ranking first in the Medical Tourism Industry (MTI) dimensionoftheMTI…isone ofthemostvisitedcountriesfor health care, with an expanded visa policy that eases travel for medical tourists. The medical visa policy allows patients tostayupto60daysandalsooffersamedicalattendantvisa forbloodrelativesthatwishto accompanythepatient.”(From Global Medical Care website.)
This is an $85-billion-per-year industry. People from all over the world – mostly from the US, Eastern Europe, Australia, and the Middle East – come to countries that offer medical tourism to get medical care and combine this with a tourism package. If their health Insurance companies cover the cost, they kill “two birds with one stone”.
My son, daughter and I discovered this at the end of our stay in Santacruz, West, Mumbai, India and got ourselves an appointment for evaluation at Hinduja Hospital in Khar East –theverynextsuburb,justafewblocks’walkfromourhome. It was completed in one day and the feedback session with the staff and consulting specialists was on the next one. All
medical records and reports of all diagnostic investigations were given to us on the first evening, and we took them with us to see the Consultants the next day. These were handed out as original documents immediately after the encounter. This was something I had never seen in the US.
Onthefirstday,thepatientcanchoosetwooptions.1.Toget the blood and other samples collected at home after NPO of 12 hours and eat breakfast at home and then present at the clinic, or 2. Present for collection of samples in the clinic at 8 AM and the clinic will serve breakfast before starting the evaluation. The labs are UA, CBC, ESR, CRP, CMP, LFT, stool examination, Urine culture, and sensitivity if indicated, PSAformen,C-125forwomen,andfastingLipidProfile.The day starts with CXR, Mammogram, GYN exam and PAP smear for women, EKG, 2-D Echo of the heart and carotids, Abdominal and Pelvic Ultrasound, Pulmonary Function Tests, Audiometry with audiogram, 2 hour post prandial blood sugar,Optometrist’seyeexam, and Dental Evaluation. The cardiac stress test is conducted on each patient, unless waived. The patient is then seen by specialist MD’s one-onone, by an Ophthalmologist, an ENT, and an Internist for a completephysicalexamination.Thisprocessiscompletedby 4PM. Thenextday,ifmeasurementsweretakenforcustommade hearing aids, the patient is fitted and tested to make sure they are correct. The meeting with the Internist includes detailed feedback and recommendations, with prescriptions. The dentist does dental cleaning if necessary and does fillings for extra fees. The last one to see the patient before theexitisaprofessionaldietician.Vitalsignsandbodyweight and height are recorded on both days. If the internist had recommended the patient to see a Pulmonologist or a Cardiologist or another specialist, an appointment is made to see him/her on the second day in the morning before seeing the Internist for the exit interview.
Thecostforthisevaluation andallthe testsisUS$250. (INR 19,000). Each patient is invited to get such an evaluation every three years. This is just health screening. If additional explorations like EGD or Colonoscopy, etc. are needed, they are available upon recommendations, at additional cost. I foundtheircarewascomparabletothatwereceiveintheUS. We can spend more than $250 in one evening to enjoy a dinner in agoodrestaurant in theUS.Didweseeacouple of foreign couples in the waiting room during our visit? We did, but patient privacy is strictly followed, and patients are advised not to inquire about others’ identities.
Sadly, the averageIndiancitizencannot easilyafford this. As psychiatrists, we are aware that our patients need basic medical care and primary care evaluation periodically. I don’t know where affordable one-shop-stop care like this is provided here in the US.
We tried to get an appointment here in Providence, RI, with a PCP or an Internist in the first week of March. The PCP’s willnottakenewpatients.Thefirstavailableappointmentwith an Internist we found was on July 3. We called again after being discharged from a hospital on May 24, but the doctor still had no opening till July 3. The nurse was kind enough to say we could take the patient to an Urgent Care clinic if there
was any need. She clarified that there is no established doctor-patient relationship – although referred by the Brown University Hospital – until July 3.
Making an appointment with a new Internist often takes at least 3 months, a neurologist 6 months. Accessing a new Psychiatrist in most cities in the UScan easily take about the same time. Physician extenders and nurse practitioners affiliated with the kind of clinic we sought help from are also not available.
What are the solutions for the problems in accessing health care in the US? My new patients tell me they figured out a way.Theycall988andsaytheyaresuicidalandgetadmitted to a psychiatric hospital. They tell me they were not suicidal, but when they were discharged, they were referred more quickly for post-acute care to a psychiatrist’s office or other specialists who provided consults in the hospital. I have tried mybestinmyofficetoaccommodatenewpatients.However, it does not solve the real problem.
Does anyone have suggestions? Whose responsibility is it?
Agism & Sexism
By: Jenny Boyer, MD
Ageism negatively impacts health, decreasing the quality of life. It has farreaching economic consequences, affecting budget decisions. Some people say it would be too costly to treat each other with more equality. But, in the end, not considering all the social determinants may cost a lot more.
Consider that the quality of patients’ lives is decreased when they cannot do what they want to do, much less what they used to do. Observe in an interview how the physician talks to the relative about an older patient, not even realizing the discounting that is going on. The interview does not focus on what the patient is concerned about, as the physician is directing questions to the patient’s accompanying person. If there is no accompanying person, then the question may not really allow for open-ended explanation of what is really the issue. Yes, it is about back and neck pain – but, more, it is about not having quality of life.
It costs financially and emotionally more if pain is not really relieved or if the patient does not fully accept that he or she can cope in ways that do not include pain pills. If the older person perceives that he or she cannot be involved in life, it is important to address or, at least, listen enough so that the patient feels heard. Pain pills do not adequately address the loss. The inequality of this type of treatment is often not realized by the physician or the patient’s relative – usually, we do not appreciate the reality of the maltreatment until it happens to us
I often let the person reminisce, to tell the life narrative and to feel like a more complete person. I ask about what he or she did in life and I do not interrupt or offer drugs. I talk about how there is meaning in sharing our memories. A patient told me he had not been to see anyone in more than a year and I asked why. He said he could not think of any reason to reach out to anyone, as no-one wanted to hear what he had to say because at 92 he was so old. I said I wanted to hear what he had to tell me. He said, “Do you have time?” I said, “I will make the time”. He and I scheduled a session where he could talk about his friends and relatives who had passed already and what those relationships had meant in his life. I did instruct him to tell me only positive experiences, so we could think about what was good in his life as a beginning.
Our conversation reminded me of those much younger people who had lost children and how much they valued the time that they had shared with them. Sometimes, I think that listening without interruption is the most therapeutic technique we have. One man went to graves over Memorial Day and reminisced out loud with those who were buried. He told them something that had happened to him since they had passed or how grateful he was for their support of him. It was not sad for him It seemed to make the relationships continue to flourish for him.
Some say that if we mention age discrimination, we appear as victims, and it is therefore better not to even mention age at all. I would argue that increased awareness will allow for increased empathy for all ages; it is not just the old that experience age discrimination.
Socio-economic inequalities can be vastly different for males versus females. When a young woman is talking about her new boyfriend the listener asks, “What does he do?” When the young man is talking about his new girlfriend the listener asks,” Do you have a picture?” Yes, this may be sex-role stereotyped, but it is dominant in our culture. Fast-forward to age 70 and the values are similar – the man is what he did in his life and the woman is not worth so much, as her attractiveness has declined. The interaction of sex and age are worse in our culture for the woman.
Educating people about ageism can help to prevent negative subconscious attitudes from developing or continuing. Bringing awareness of what is experienced with age in our culture can prevent the negativity from being as bad. For example, we could appreciate stability of relationships, the accumulation of wisdom and money, and the benefit of learning from life’s mistakes. There is much to be positive about, but the information is skewed to the negative. We make jokes about people sleeping in meetings as a sign of age. We make fun of loss of sensation in the feet that causes older people to appear less confident when they walk. We fail to recognize that better decisions are made by older people, based on their life experiences.
After all, everyone is young at first and everyone (unless they die first) ages. It’s the best example I know of everyone eventually being treated equally.
Prejudice against the young also exists. We tend to think it is funny when someone is taking risks and bears the consequences. We think younger people do not need the same insurance, as they will be fine, given how young they are. Then they are unprotected financially when they have a car accident and need expensive treatment to survive.
Here is the AGE Platform Europe (a network of more than 150 organizations that works to combat aging) vision: “Age equity is an inclusive society, based on well-being for all, solidarity between generations and full entitlement to enjoy life, participate in and contribute to society.”
Particularly because we are physicians, we need to advocate for hospital and regulatory policy that is focused on how individual physicians do rather than on their age I recently had surgery that was performed by a physician in his 70s, and I had challenges from younger people about why would I let him perform it. I had examined his record of surgery, not the age itself. We have to look at performance on a case-by-case basis, as some older people are very competent.
The Southern could help our members be more sensitive to these issues so that they can avoid perpetuating the stereotype that aging is bad.
Dr. Steven Sharfstein Becomes President of the Senior Psychiatrists
On May 7, SPA member Steven Sharfstein became president of the APA’s Senior Psychiatrists for a twoyear term.
He commented for Southlands:
“The goal of every psychiatrist is to achieve “senior” status. “Living long and living well” is our aspiration. The Senior PsychiatristscomprisethemostwelcominggroupintheAPA. To be eligible to join, you need only to be over 65. Over 40% of the membership of APA has achieved this milestone and most of us are “lifers” – Life Members, Fellows and Distinguished Life Fellows. Currently, we have over 300 members. Membership is free, although we appreciate any voluntary donations.
So, what do The Senior Psychiatrists do?
We gather at the annual APA meeting, give talks on the scientific program, socialize with each other at a wonderful partysponsoredbyPRMS,presenttheannualBersonaward to a senior member of APA who has made a significant contribution to psychiatry, publish a newsletter, and mentor
younger colleagues. We have a Rep at the APA Assembly and sponsor Action Papers – most recently, one on ageism in America. During the year, we interact with the APA Library and Archive on the history of our profession and the APA. These “oral histories” become a part of the legacy we all contribute to our profession. From time to time, we present webinars for APAmembers on a variety of clinicaltopics and on issues related to retirement.
So,ifyouareeligible,considerbecominga“Senior”.Ourweb site is https://seniorpsych.org. Join today!!”
Department at LSU Health New Orleans to Address Prison Care
By: Rahn Bailey, MD SPA Board of Regents Member
Prisons house the largest mental health facilities in America, with nearly 20% of inmates having serious mental disorders. Because of rising recidivism rates, timely access to mental health services and delivery of psychotropic medications to inmates are crucial.
New Orleans typifies this crisis. Socioeconomic and health disparity in the city contribute to high local prison volume. Correctional psychiatry services are challenged bycomplex factorsoperatingwithin and outsidetheprison population.
As of June 2024, my Department of Psychiatry at LSU Health New Orleans is providing services to inmates of Orleans Parish Prison. This landmark agreement is planned to bring an up-to-date and transformative approach to addressing the needs of the prison and its inmates.
I will be overseeing the delivery of these services, plans to use empirical data to guide him. This operation will feature a group of clinical faculty who represent a wide range of psychiatric subspecialties, including Child and Adolescent, Addiction, and Forensics. They will work with trainees, so it will be a teaching experience as well as a chance to improve the ways services are delivered.
I expect that the success of this project will be felt by the entire New Orleans community both inside and outside the prison walls.
Dr. Rahn Bailey Receives National Award
Dr. Rahn Bailey, a member of the SPA’s Board of Regents, is the recipient of the 2024 Solomon Fuller Carter Award, which recognizes someone who has pioneered in an area that has significantly improved the quality of life for Black people. He received the award at the APA meeting in New York in May.
Dr. Bailey is Professor and Chair of Psychiatry and Assistant Dean of Community Engagement at LSU Health New Orleans. He has 86 peer review publications and has published 3 books Much of his work has centered on Black adolescent violence prevention He has elucidated some of the risks and protections concerning violence exposure inthis group, whichcontributes tomore inclusive mental health assessments and intervention. His work has clarified the association of structuralbarriers to gun violence in New Orleans and has provided insight on youth experience and coping with city violence
Dr. Solomon Carter Fuller was the first African-American psychiatrist. A leader in research into Alzheimer’s disease, he is also recognized for describing the effects of syphilis. Dr. Fuller grappled with racial discrimination. He died in 1953, leaving a legacy that continues to motivate all those who are trying to make health care more inclusive.
TMS for Opiate Use Disorder
neurotransmitterBy: Jeffrey Taylor Owen, Medical Student, G. Randolph Schrodt, Jr., M.D. & Ali A. Farooqui, M.D., Clinical Professors, University of Louisville
Over the past two decades, there has been a 6-fold increase in the number of people who have died from overdoses. Since 1999, a total of 645,000 have died from overdoses related to opioid use including prescription and illicit opioids. Over 2 million people report havingan opioid use disorder (OUD).
The complexities of OUD extend beyond the initial opioid exposure and involve neurobiological, psychosocial, and environmental factors that contribute to the persistent nature of addiction. The neural circuitry of addiction includes structures in the striatum such as the nucleus accumbens and the prefrontal cortex, specifically the orbitofrontal cortices and the anterior cingulate cortex
Novel therapeutic interventions have garnered attention in order to address the limitations of current treatment modalities. Transcranial magnetic stimulation (TMS) is a promising and innovative approach, leveraging noninvasive neuromodulation techniques to target the specific brain regions associated with reward, craving, and impulsivity. Although large-scale trials have been conducted in the areas of alcohol use and smoking cessation, there islimiteddataontheuse ofTMSinopiate use disorder.
Opiates present the risk of overdose, which complicates research, particularly randomized controlled trials. The potential life-saving nature of current treatments introduces ethical considerations, as withholding effective interventions for the sake of research can pose serious risks. Therefore, TMS studies in the context of OUD often center on evaluating its efficacy as an adjunct treatment and its effect on cue-induced craving and reactivity.
One factor that has been shown to lead to poor outcomes in OUD treatment is comorbid depression. The safety and efficacy of TMS have been established in the treatment of depression, with the dorsolateral prefrontal cortex (DLPFC) as the target brain region. This region is also implicated in impaired inhibitory control in drug addiction, showing hypoactivation during motor response inhibition tasks, and is involved in executive functioning and cognitive control – making it a promising target for stimulation in patients with OUD.
When used adjunctively in patients undergoing methadone treatment, TMS did not appear to reduce craving for heroin on the visual analog scale, but did reduce depression scores. These results were contrary to the established literature, which suggests that TMS does reduce craving for opiates. Metanalysis suggests that not only is DLPFC stimulation effective in reducing craving, but that multi-session protocols are superior to shorter protocols. This suggests a cumulative dose effect on craving and consumption. This discrepancy could be the result of earlier studies focusing their treatments on patients who had a 20-year history of opiate use and only received 11 TMS sessions – compared to the standard 36 sessions indicated in the depression protocol.
Reduction in craving has also been documented in patients with methamphetamine use disorder following DLPFC stimulation. This finding was replicated in patients with OUD, where high frequency TMS over 4 days resulted in a persistent reduction in cue-induced cravings. The use of intermittent theta burst stimulation (iTBS) produced similar results.
OUD is a public health crisis. In addition to mortality associated with the disorder, there is a significant amount of comorbidity with other psychiatric conditions such as depression. Although a few different brain regions have been identified as potential targets for brain stimulation, the DLPFC has been studied in the majority of the literature. Results suggest that stimulation reduces cravings in a dose-dependent manner and reduces symptoms of depression. More studies are needed to determine if other potential targets would be more efficacious, and if there is a role for non-invasive brain stimulation in the standard treatment of addiction.
Exercise Plans? Counting Calories? Exercise Done is Better than Exercise Not Done
By: Steven Lippmann, M.D.
Obesity is gaining prominence within psychiatric and other medical practices. Americans are heavier than they were previously, and physicians are concerned how that hampers health and life expectancy.
Bruce Hershfield asked why I wrote an article about exercise: Well, I first got interest in this as a Boy Scout working for Health and Public Health merit badges, while seeking to become an Eagle Scout. Otherwise, I was only an intermittent exerciser. During medical school in Galveston, it was fun running in sand at the beach. For most of my physician life, my exercise varied widely. During stressful times, working out was an occasional coping strategy. Then, for much of the 2000’s, my internist persuaded me to gradually increase the frequency and duration of neighborhood jogging; I often complied, but not always consistently. Retired and after the early 2020 advent of COVID-19, I became a very regular jogger, one hour every single day. That regimen is helpful in my physician volunteer, indigent medical care practice. Here I do cite my behavior while recommending physical activities to patients, who often are obese and all economically disadvantaged. This is clinically important because so many have hypertension, hyperlipidemia, diabetes, depression, pain, and related issues. Encouraging their exercise reinforces my zeal to sustain my daily regime, and it also role models my medical trainees to increase their physical activities.
It is usually easier to gain pounds than it is to lose them. People with psychiatric illnesses are particularly prone to weight gain, and several of our medications increase this tendency. The advent of expensive diabetic medications that induce weight loss has re-emphasized obesity issues. Standard weight loss recommendations: eat less, improve dietary habits, get adequate sleep, and do regular exercise. Physicians recommend these plans, but they are rarely sustained. Similarly, many people pay to join a gymnasium, only attend for a while, and then drop out.
What people want is a “magic cure”; perhaps, a pill that quickly and permanently gets rid of fat. Who wants to do hard work? Slimming is difficult and people frequently relapse into the habits that produced their obesity. Also, people often drink and eat less-healthy, but inexpensive, high-calorie beverages and foods.
Some people are suggesting that many physicians are over-preoccupied with weight in a way that is counterproductive. They say that a focus on the body mass index (BMI) induces shame and guilt, harming health and selfesteem. They also note that the BMI is not a consistently accurateappraisal method. Someofthosestatements are valid. Nevertheless, too-high fat content of the body,
especially of the abdomen, escalates hypertension, hyperlipidemia, vascular disease, joint dysfunctions, and related risks.
What about exercise? First of all, it is nearly impossible for most people to use exercise as the only weight loss plan. For example, eating a piece of apple pie would require walking fast for about three miles to burn those calories. Most folks would not even consider that option. It is not time-reasonable for most people to do that much exercise. Unfortunately, many individuals with eating disorders and/or other body weight concerns do overutilize physical activity for prolonged periods as a method of reducing their weight.
My father said, “Do everything in moderation.” Good idea. For weight control, a combination of regular dietary control and exercise is best. Such a modest regimen ought to be part of one’s routine. In recommending an exercise plan, advise the patient to do what they like. Begin with a mild program, like a short stroll, and gradually escalate it over time. Any exercise is better than incompatible with their circumstances, health, and/or available time. For example, some people park their car away from the entrance of buildings to enforce some activity or take the stairs more often. Walking, jogging, or running are common ways to exercise. These can be done at home (on treadmills), in neighborhoods (on streets, tracks, or trails), or at a gym. Swimming is an excellent alternative that is easier on joints, but generally less accessible.
Which is better? Thermodynamics dictate that the amount of work performed is proportional to the energy required. Thus, “faster and longer” uses more energy and potentially results in less calories available for fat storage. “Faster” also requires more muscle activity, and theoretically, if sustained over time, also yields muscular mass gain and/or preservation. And muscle uses more calories even at rest than does fatty tissue. Even when the same weight is transported over equal distances, increasing the speed escalates the energy usage.
Walking is efficient and uses fewer calories than running. The walker’s weight does not need to be lifted up and down with each step, since one foot is always in contact with the ground. That means less muscular work and less energy consumption. A heavy body uses more energy than a lighter one at the same speed and distance. Some people do not like that walking takes longer to achieve the same calorie consumption as running. Walking is safer than running, since a slower pace is less likely to result in ankle sprains, joint issues, or falling.
What about jogging or running? A faster gait uses more calories. With each stride, there is a brief moment when neither foot is on the ground; thus, pushing forward requires more muscular work. Being momentarily airborne with each step, the body must be repeatedly pushed upward and then falls downward. To become airborne at each stride requires more effort; also,
supporting oneself on one leg after gravity pulls the body downward, necessitates greater muscle power to counteract that force and to maintain balance.
What about exercise on a treadmill, for the same amount of time? A treadmill yields forward motion via the movement of the machine’s belt. Its cushioning results in some treadmill-upward return-motion that reduces the physical activity required. Treadmill exercise utilizes fewer calories than walking or running on a street but is easier on joints. To counteract the mechanical advantages of the treadmill, an exerciser can raise the machine’s tilt.
Exercise can optimize heart, brain, and kidney vascular health, maintain balance, improve emotional “wellness,” build or maintain muscular strength, aid sleep and calm anxiety. Lots of people enjoy exercise or sports that provide mental comfort and increase social contacts. Low impact activities like yoga or tai chi, or more robust activities like judo, karate, or jujitsu are popular.
Whatever exercise that the person is willing to continue is the best over the long term.
Shortage of Doctors and Nurses: Some Orgins Solutions Are Harder to Find …
By: Steven Lippmann, M.D., Emeritus Professor, University of Louisville School of Medicine
Yes, there were shortages in healthcare personnel decades ago. However, since the advent of computers and the coronavirus epidemic, this situation has worsened. Now, there are not nearly enough physicians and nurses throughout the country. Nurse practitioners and/or physician assistants fill some, but not all gaps, but deficiencies still cause hardships and suboptimal care throughout the richest country in the world. Delivery of care is often delayed. Do you hear about people having trouble quickly scheduling an appointment or referral, or experiencing prolonged ER waits? How can that be?
Physicians are unhappy about these shortfalls. So are our patients! Nurses are stressed by overwork; traveling nurses go from one facility to another without loyalty to a place or group. All this yields suboptimal medical care; professional services decline, and patient-to-clinician relationships deteriorate. One potential improvement could be that regular nurses would be given the extra dollars paid traveling nurses; that would improve morale and decrease personnel turnover. Nevertheless, a “quick fix” is not easily evident.
For most of my professional life, seeing patients while not in a rush, easily getting test results, obtaining medicines or procedures, making referrals, and writing clinical notes
was easier and more gratifying. Currently, we have too many bosses, political regulations, legal constraints, and rules that compromise patient care and leave everybody dissatisfied.
“Prior authorizations” are just one example. This procedure wastes time forclinicians, pharmacists, and the frustrated, waiting public. Most everybody hates this, but business has interfered with our ability to sustain a healthpromoting, pleasurable work environment. Insurance companies earn more money doing this, but few people benefit from these arrangements. Doing away with prior authorization would free more time for clinical involvement.
Electronic medical records have made the situation worse. Nurses and physicians now spend too much time working on computers rather than with patients. The electronic chart has become a place for enumerating voluminous details that are only partially pertinent. These records impair the ability to quickly understand clinical issues. Too much time is spent “checking boxes” rather than personally attending to patient needs. We should have a means to quickly record succinct notes that focus on clinical concerns. A return to more quality patient contact with less charting time should regain some job satisfaction. That should promote comfort for all involved. Sir William Osler cautioned us that while we seek cures when possible, providing comfort is our consistent objective.
As a temporary fix, we now have scribes and computerized dictation technology to transcribe some of the notes. Yet, this costs more money and many doctors report that they have no time to proofread records for accuracy, completed by less-medically trained people and/or machines. Nurses voice similar issues. Medical workers increasingly experience disappointment, “burnout,” and/or premature exit from healthcare. I know physicians who have given uptheir practices just because of this issue.
As an academic medical school physician, I initially had two secretaries in the late 1970s who cared for my paperwork, my scholarly activities, and my administrative assignments. As computers appeared, employers diminished the amount of support staff. Many healthcare professionals now spend time “pecking-away” at writing reports, filling out documents, providing recommendations, and the like – stuff that staff previously provided. Nowadays, medical professionals type faster and better understand computer algorithms; however, they have lost time to focus on patients. Is there any wonder as to why practitioners are in less available supply?
It is advantageous to have a trained secretary, instead of medical personnel, do office work. Laborious charting leaves medical staff unable to care adequately for our current clinical load. People prematurely leaving the health professions means there are fewer practitioners to
care for patients. Meanwhile, our society begs for better access to affordable, timely care.
Since the electronic record arrived, healthcare personnel are more rushed, often stay after-hours, and/or bring work home to finish charting. The rise of “concierge” medical practices is no surprise. The doctors want lower patient volumes with more individualized patient contact and greater autonomy. However, this raises costs and decreases the number of patients receiving care. The system could benefit from more input from medical personnel.
The huge number of people without health insurance is another issue. Medical bills are the major cause of bankruptcy in our country. The corporatization of medicine is much of the problem. Takeovers by large healthcare companies, hospital chains, and insurance firms deliver less individualized care and diminish competition. Administrators on high salaries seem to value profits over patient and/or employee satisfaction. Micromanagement oversight by those not involved in direct care wastes time on non-clinical tasks and is less effective. Malpractice concerns add a burden and expense. All that causes dissatisfaction, less quality, fewer people served, and younger age retirements.
Are our citizens happy? Many other nations provide healthcare with better results, for a larger percentage of the population, and at less cost. Many of our clinical outcome measures show that we lag behind lots of other countries.
Who likes this situation? Society, healthcare staff, and public officials need to jointly work out some solutions.
What Music Therapy Can Do Music Therapy in Medicine – Turkish Style
By: Sumeyra Baskoy, M.D., Oasis Family Practice, N.
Miami Beach, FL & Steven Lippman, M.D , University of Louisville
During my medical school years, I (Dr. B.) was accepted into the Bursa Merinos Music Conservatory for Classical Turkish Music. Despite putting music studies on hold in my second year, I had an enriching experience in that educational institution. It gave me insight into the modes of Turkish classical music, such as Hicaz, Nihavend, Huzzam, and Segah. I delved into how music was applied as a form of psychotherapy during the Ottoman Era.
The connection between human nature and music fascinates me. Nature embodies rhythmic sounds –whether rain, storms, wind, flowing water, birdsongs, or even the moment of an earthquake. From the lullabies mothers sing to soothe their babies, to heartfelt lamentations, and/or joyous celebrations, music has
forever been intertwined in our lives. Music arises emotionally from within as a profound awakening or inspiration.
The relationship between music and healing has a rich history, dating back to Shamanism, the Seljuk, and Ottoman periods. Early Turkish physicians provided melodies to soothe patients experiencing fear, anxiety, doubt, or spiritual turmoil, while monitoring their pulses, to find the tune most suitable for each individual. They even brought together patients with similar ailments for group therapy sessions. This treatment approach continued through various cultures and historical periods.
The Darüşşifa operates as the Health Museum within the Sultan II. Bayezid Complex in Edirne and is an historical medical facility. It served as a psychiatric inpatient unit duringtheOttomanperiod, offeringmedicaltreatment and patient care with music.
The relationship between human temperament and music was extensively investigated during the Ottoman era. The effects of various musical modes on individuals at different times of the day were examined, and classifications were made based on their impact for different ethnicities and illnesses. They postulated associations between skin tones / racial backgrounds and specific musical styles. A famous Turkish scholar, Abu Bakr Razi, who lived between 834-932 AD, described the treatment of people with melancholia, emphasizing engagement in enjoyable activities, social interactions, and music as essential components of therapy.
Al-Farabi, another great Turkish scholar (870-950 AD), in his work "Musiki-ul-Kebir," attempted to explain the relationship of music with physics, astronomy, and the soul. For instance, he associated different music styles with various emotional states.
Avicenna, also known as Ibn Sina, applied music in medical practice and believed that music therapy consists of several essential elements. These include understanding rhythmic patterns, appreciation for music, participation in group settings, ensuring patients work harmoniously, improving posture/motor skills, practicing songs/breathing exercises, and prescribing tasks to patients that align with their personalities.
An analytical study in the field of music by Frieda Teler was published by Imago V. (1917-1919) under the title "Enjoyment of Music and Phantasy". Further research on music and psychoanalysis was conducted by Henrich Packer in 1951 –“Contribution to Psychoanalysis of Music". Like Freud's conceptual model of the psyche, music therapy can satisfy some of the pleasure orientation of the ego, super-ego, and id through the free expression of desires and pleasures, fulfilling the ego's reality principle. Music performance encompasses a ”four functions of the psyche” described by Jung: thinking (translating notes into music), sensation (expressing emotions through music), intuition (evidencing the composer's beliefs), and feeling (proprioceptive feedback of the musician).
According to Adler, music performance can bolster individual willpower. It allows individuals to harness their emotions for a more fulfilling life rather than succumbing to self-harm by using disability to dominate others. It can lead to a more beneficial lifestyle.
Music is a universal art form used by people of all races and religions throughout history. It is an integral part of our lives. It can have a role in psychotherapeutic sessions where it might help patients understand their own emotions.
I suggest you search for "Buselik Makami-Turkish Music Therapy" on YouTube and listen to the rendition performed by Rahmi Oruc Guvenc with your eyes closed. The Buselik music mode can strengthen, encourage, and bring peace to the soul!
Artificial Intelligence in Psychiatry: Boon or Bane?
By: Nishi Chandrasekaran, M.B.B.S. Sree Balaji Medical College and Hospital, India
Artificial intelligence (AI) seems to be replacing years of human efforts. That prompts questions, including about its application into the practice of Psychiatry. Its capacity to improve diagnostics and treatments is commendable. This is evident with studies in translational psychiatry, where an AI algorithm was seemingly able to accurately predict response to antidepressant drugs, using neuroimaging data. Another study indicates that an AI algorithm was able to identify subtypes of depression based on neuroimaging and genetic data.
But there are concerns about how accurate this is and also about privacy and security. While patients are willing to share their psychiatric status and related information with their doctors, there are overt fears about possible misuses. People generally are also willing to share their data with mental health apps, if assured about security
and confidentiality. Of course, nothing transmitted via the internet connection is truly secure.
Subjective bias is part of human nature – and also of AI, because of the data used for its development. Such concerns were documented in an AI algorithm designed for suicide risk prediction. This model results in rather accurate assessments for White, Hispanic, and Asian individuals; but less so among Black, American Indian/Alaskan Native populations, and individuals with unspecified race/ethnicity. Such preconceptions can emerge from systemic racism causing unequal treatment of racial minorities.
Especially for high quality data; there is a potential to “overfit” – acquiring insignificant connections between patient attributes and outcomes. This occurs due to an excessive number of variables influencing results. Consequently, while the algorithm might perform well in a training dataset, its accuracy diminishes when projecting future events. Concerns also arise regarding data leakage. If the algorithm attains high predicted accuracy, its capacity to anticipate events beyond the training dataset weakens, potentially stemming from information incorrectly linked to outcome. A fresh dataset may then be required to validate results.
Another investigation indicated that AI utilized to predict depression outcomes based on social media data had lower accuracy, when developed from data derived from a single platform. This study documents that a combination of various deep learning (DL) algorithms resulted in heightened precision, compared to relying on individual ones.
The efficacy of DL algorithms from datasets related to depression was more precise as compared to other datasets and algorithms. The employment of the Convolutional Neural Network (CNN) – Long Short-Term Memory (LSTM) algorithms on datasets pertaining to depression yielded good outcome predictions.
The implementation of AI in psychiatry has the potential to enhance diagnostic accuracy and treatment. It might assist earlier detection of mental health issues, personalize therapeutic plans, and improve clinical efficiency. However, there are issues that must be addressed – such as the lack of human interaction, questions about privacy, data security, potential biases, and technical limitations. We need to assess the ethical and legal implications of using it. Future research should focus on developing transparent, interpretable, and comprehensive AI algorithms to maximize benefits while minimizing harm.
Long-Acting Injectable Treatment for People Suffering Opioid Abuse
By: Orlando Maldonado, M.D. PGY-2 Psychiatry Resident & Steven Lippmann, M.D.,
I, Orlando Maldonado – a second-year psychiatry Resident at the University of Louisville – was first exposed to the consequences of opioid use through a friend whose parents and younger brother struggled with drug abuse while we were in college. During medical school and residency, I rotated on substance use disorder services and observed patients avoid potentially lethal substances, restore social relationships, and regain productive pursuit of their lives. These experiences stimulated my interest in opioid agonist therapy.
I, Steve Lippmann, have a long interest in substance abuse issues that began while I was medical school. It heightened during 1970-1973 while I was in the service because soldiers were having so many drug problems in Vietnam and drug abuse was so epidemic in the U S civilian population. For one of those years, I was a U S Public Health Service General Medical Officer stationed at the U.S. Narcotics Hospital. During psychiatry residency, I also did three years as a general practice emergency room physician, moonlighting every Tuesday night. Since 1976, I have been a faculty member at the University of Louisville – including as an inpatient attending and also doing some consultation and outpatient clinic work. Since retirement – for nearly a decade – I have been a primary care doctor at a free Louisville medical clinic. Caring for patients who abuse drugsandseeingthenegativeeffectsit causeshave been an all-too-consistent part of my professional life.
Opioid use disorder (OUD) continues to be a public health and economic burden, causing many overdose deaths. Methadone and/or buprenorphine are the main pharmacotherapies for people with OUD; however, their efficacy is limited because of suboptimal adherence. Injectable, extended-release formulations of buprenorphine could improve that by providing prolonged blockade of subjective opioid effects, removing the need for daily medication.
Research reveals that a higher percentage of subjects became responders to depot buprenorphine treatment as compared to the sublingual buprenorphine/naloxone group (17% vs 14%). There was no evidence of illicit opioid use at prespecified points throughout a 24-week trial. A meta-analysis comparing methadone and buprenorphine in treating people with opioid dependence evidenced that retention was higher with extendedrelease buprenorphine at 6 months (66%) and one year (74%). It was similarly so with methadone (56% at 6 months vs 47% at one year) and also for sublingual buprenorphine (52% vs 43% at 6 months). The reliability of these findings was limited by the low number of
extended-release buprenorphine studies and by uncertainty around the estimates.
A phase 3, open-label, 48-week trial demonstrated that subcutaneous buprenorphine depot treatment is safe. The most common treatment-emergent adverse events were pain, swelling, or injection site erythema (15%, 12%, and 9% respectively). Nasopharyngitis, headache, nausea, dysuria, and/or vomiting occurred in under 8%. Only 2% of subjects withdrew from the study due to side effects.
While it is important to offer a variety of modalities, treatment must be individualized for each person. For example, some report that the daily routine of taking a medication helped their recovery. While some patients view the increased distance from medical settings associated with extended-release formulation as convenient or decreases the stigma, others think of it as potentially coercive. Another limitation of this extendedrelease drug is cost; trans-mucosal buprenorphine is about $196/month, compared to $1,136 for the extendedrelease preparation. With multiple extended-release formulations now available (e.g., Sublocade, Brixadi) that cost may decrease with increased competition.
Extended-release buprenorphine is a good option to help people stop abusing opioids. This formulation is not a cure-all. Limitations of access and cost must be considered, and many patients drop out even when using extended-release pharmacotherapies.Nevertheless,they can play an important role when treating opioid abuse in appropriate patients.
From Ancient Roots to Modern Times
Psychedelics in Psychiatry
By: Milad Mehrbod, M.D., Researcher Physician & Steven Lippmann, M.D.
My (Milad Mehrbod) deep interest in how we perceive reality has always fascinated me, with psychedelics being a particularly intriguing aspect. Through my medical education, I became more familiar with these substances and renewed my interest in them. I have encountered numerous personal testimonies on their profound effects. However, these claims require rigorous scientific scrutiny to determine if they are not just hype, glorified by some enthusiasts.
My (Steven Lippmann) initial exposure to psychiatric treatments began at the University of Texas Medical Branch in Galveston, where psychiatry was the biggest department, in the medical center that was the major tertiary referral center for all of Texas. I even remember participating in insulin shock for patients in those days. During my time in the service (1970-1973), for one year, I was stationed at the United States Narcotics Hospital in Lexington, KY. There I learned much clinically about
substance abuse and its interventions. I heard lots of interesting stories from soldiers returning from Vietnam and also from civilians about their personal experiences with psychedelic substances. Now, five decades later, research and news about the potential benefit of psychedelic pharmacotherapies are prominent.
These agents augment selective brain activities and promote new synaptic connections. These changes can re-set some neuronal circuits linked to psychiatric disorders, offering hope where traditional therapies were not successful. Psilocybin exists in certain mushrooms, for example, and has reduced symptoms of depression and/oranxiety after justonedose,highlighting itspotential for diminishing emotional distress.
The cultural implications and historical usage of these agents date back to ancient times, when they were often intertwined with religious and spiritual practices. Psilocybin-containing mushrooms and other natural psychedelics have been used in shamanic rituals to enter altered states of consciousness. Aztecs, Mayans, and some other Native Americans appliedthem in ceremonies to try to communicate with their gods and perform healing rituals. In the Middle Ages, alchemists sometimes used psychoactive plants, although such practices were often suppressed.
The discovery of LSD in 1938 by Albert Hofmann was a turning point in the history of psychedelics. The number of studies increased in the 1950s and ‘60s. Timothy Leary and Richard Alpert (later known as Ram Dass) advocated psychedelics in exploring consciousness and treating mental health concerns. This era also included some nonconsensual experiments by the U S government, using psychedelic substances to develop techniques for psychological warfare, which led to moral outrage.
Intravenous infusion of ketamine, an N-methyl-D-aspartic acid (NMDA) receptor antagonist with psychedelic and dissociative aspects, has antidepressant properties, even in treatment-resistant subjects. Repeat-dose trials have confirmed efficacy and safety with improved mood and less suicidal thinking. It is also being researched for its potential benefits for people with alcohol abuse and/or obsessive-compulsive disorders. Among some cancer patients, it can diminish emotional distress.
Ayahuasca, a South American plant-based brew, may alleviate depression and/or anxiety, related to its interactions with serotonin receptors and its effect on neural plasticity. It decreases blood flow to the amygdala, a region associated with fear and emotional responses, which may explain some of its benefits.
Studies are needed to evaluate the safety and efficacy of combining psychedelics with other therapeutic modalities, such as psychotherapy. Recently, the Food and Drug Administration declined to recommend 3, 4methylenedioxymethamphetamine (MDMA) for treating post-traumatic stress disorder, due to insufficient
evidence and concerns over trial misconduct and/or data gaps. This highlights the ongoing scrutiny that needs to be satisfied. Despite the promising results of using psychedelic substances in treating people with various psychiatric disorders, their acceptance into mainstream psychiatry is not without challenges.
In 2023, the Kentucky legislature allocated $42 million from its Opioid Settlement Fund to support psychedelic investigations. This investment aims to explore the therapeutic potential of substances like ibogaine and psilocybin. Perhaps it may have use at opioid addiction interventions and in alleviating other psychiatric conditions. Managedby a state-appointed committee, this money should aid universities and institutions at conducting clinical studies; some are already underway.
In the same year, Kentucky's ibogaine research proposal, supported by a coalition of investigators and advocacy groups, plans to study its potential in mitigating opioid addiction. The proposal is currently being reviewed by the Kentucky Opioid Abatement Advisory Commission. If approved, comprehensive studies and clinical trials to assess ibogaine's safety and effectiveness will be started.
Glutamate: Neurotransmission and Brain Function
By: Milad Mehrbod, M.D
Mahya Beyki, M.D. & Steven Lippmann, M.D.
As an Iranian doctor who immigrated to the U.S.A. in 2018, I (Milad Mehrbod) am marking a new chapter in my life. A fascination with the human psyche and consciousness began in my early teenage years. I passionately read every book, article, and post I could find about psychedelics, near-death experiences, lucid dreams, hypnosis, and related metaphysical topics. I became familiar with biochemical pathways and discovered that consciousness might originate in the brain's intricate interactions of electrical and molecular forces. A few years later, a lecture on ketamine and dextromethorphan's implications for depression inspired me to study glutamate under Dr. Rif El-Mallakh’s guidance. I was fortunate to have Dr. Steven Lippmann's mentorship throughout my studies. (Dr. Lippmann added, “Glutamate has been on my mind for some time –including when I heard about it from my physician daughter and from Dr. Rif El-Mallakh, and I have had a long, deep interest in it.”)
The scholars mentioned above sharpened my curiosity about human consciousness.
Glutamate is a primary excitatory neurotransmitter in the central nervous system, playing a role in synaptic plasticity, learning, and memory, and influencing neurological disorders.
In 1907, research about the unique taste of kelp led to the identification of umami, as a so-called “fifth basic taste” that was attributed to the presence of L-glutamate. This prompted creation of a new glutamate-based seasoning agent, monosodium glutamate – a new way to enhance flavors, especially in Asian cuisine
Glutamate is the brain's most abundant excitatory neurotransmitter. It influences aspects of the sleep-wake cycle, energy metabolism, and pain signaling It also affects synaptic plasticity by inducing structural and functional changes, essential for learning and memory consolidation. It allows for the selective 'pruning' of lessutilized neural pathways, ensuring a balanced, efficient neuronal network Its release can initiate excitatory signals, activating intracellular signaling, leading to neuronal activation and propagation of electrical impulses.
These roles within the CNS highlight its potential for therapeutic interventions. Prolonged stress affects the glutamatergic system by impairing neuroplasticity and cognitive functions. Research about glutamatergic agents, like ketamine, indicate promising ways to attenuate mood disorders such as depression and/or anxiety.
Glutamate imbalance influences neuropsychiatric diseases through two main pathways. First, excessive release or insufficient removal can lead to neuronal injury or death. This is implicated in conditions following brain injury, and in neurodegenerative diseases including Alzheimer's, Parkinson's, and Huntington's Secondly, abnormalities in glutamate signaling interfere with neural circuits, impacting psychopathology as in schizophrenia and/or mood disorders. These effects are attributed to changes in receptor and transporter functions, marking a distinction from the neuronal damage associated with excitotoxicity.
Because it helps regulate fat metabolism and appetite, mediated through neural circuits, it is involved in weight control. Furthermore, it also affects stress and anxiety responses, which can alter eating patterns. It is also involved in modulating plasma glucose levels and thermogenesis. After high-fat meal ingestion, brainstem astrocytes trigger glutamatergic modulation of information transmission to vagal neurons, thereby regulating gastric activity and food intake. Its presence within dietary sources and cellular metabolism impacts normal and disordered neural activities and underscores its importance.
Our understanding of how glutamate impacts brain function suggests important potential treatment approaches for treating neuropsychiatric disorders.
