Southlands June 2022 by articles

SOUTHLANDS The Newsletter of the Southern Psychiatric Association Volume 8, Number 1 JUNE 2022 Article Title

Author

The President’s Column Executive Director Update Report from the APA Assembly Call 988! A New System for Getting Help for People in Crisis The Growing Promiscuity of “Bipolar Disorder” Behind the Curtain: My Family’s Ordeal as Healthcare Consumers Dorothea Dix: A Remarkable Woman. A Reformer for the Ages Interview: Mark Wright, MD – SPA Rep to the Assembly “Provider”: A Problematic Term for Psychiatry Hope Deferred The APA Board’s Structural Racism Accountability Committee: Slowly Moving the Needle South Asians: A “Forgotten Minority” Monkeypox 101: What a Psychiatrist Should Know Oral Anti-Coronavirus Pharmcotherpay?

David Casey, MD Janet Bryan Mark Wright, MD Jenny L. Boyer, MD William Greenberg, MD Felix Torres, MD

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Steven S. Sharfstein, MD Bruce Hershfield, MD Jonathan R. Scarff, MD Tina Thomas, MD Felix Torres, MD

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Tina Thomas, MD Steven Lippmann, MD Aya Allam, MD, Steven Lippmann, MD

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What? Fluvoxamine is an Anti-COVID-19 Drug?

Omar Elsayed, MD, Ahmad Sleem, MD, Ali Farooqui, MD, Steven Lippmann, MD Ankita Nair

Asha Mahajan, Ali Farooqui, MD, Rif El-Mallakh, MD Ben Sanders, CO, Ziad Ali, MD, Steven Lippmann, MD Alex Van, Hema Madhuri Mekala, MD, Steven Lippmann, MD Gary Weinstein, MD Shree Vinekar, MD Bruce Hershfield, MD Bruce Hershfield, MD

My Experience as a Medical Student in 2020 and during COVID19 Botulinum Toxin is a Possible Treatment for Major Depression Lithium Nephropathy Prescribing Practices Ketamine Diminishes Suicidality How to Handel Sexual Feelings in Clinical Practice Dr. Harold Eist – A Profile in Courage In Memoriam: Harold Eist, MD Letter from the Editor: Together Again Save the Dates: 2022 & 2023 Annual Meeting Dates

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The President’s Column By: David Casey, MD

Professional Risk Management Services (PRMS) was well-attended, and everyone seemed to enjoy it. Our first “virtual social event” is scheduled for Tuesday, June 28, at 8:00 p.m. Eastern Time. We are hoping to schedule these on a regular basis so we can connect outside of our receptions at our Annual Meeting and at the APA’s. I hope to see you on the 28th!

Greetings to my fellow members of the SPA! I enjoyed seeing many of you in person, along with other guests, at our reception at this year’s annual meeting of the APA in New Orleans, co-sponsored by PRMS. What a pleasure to be able to congregate with friends and colleagues, old and new, face to face at last!

The Program Committee, in conjunction with the Maryland Psychiatric Society, has been meeting since the beginning of the year. This year’s topics are very timely, including firearm panel, trauma informed care, neuromodulation, use of psychedelic psychotherapy in mood disorders, chronic pain and opiates, COVID-19 updates, geriatric panel, treatment in pregnancy, history, art and psychiatry, child & adolescent panel, Shreveport as a leader in early opiate addiction treatment, and DSM5-TR. The program agenda and registration form are attached.

In addition to hosting, the Big Easy provided endless opportunities to enjoy good food, entertainment, and socializing. My wife, Valerie, and I especially enjoyed the aquarium and the World War II Museum. As the children of World War II veterans, we were both greatly moved by the presentations. The APA meeting itself provided much food for thought. I attended a presentation by Dr. Altha Stewart, first African American president of the APA. She emphasized her lifelong, persistent, consistent, and insistent work in promoting equity and opportunity for African Americans within the APA, Psychiatry, Medicine, and society. This lecture resonates with me as I write this column on the cusp of Juneteenth. A very thought-provoking awards lecture by Dr. Charles Nemeroff pointedly called into question the utility of genomic testing – at least, the currently available generation – in Psychiatry.

After two years of virtual meetings, we are looking forward to an on-site meeting at the Royal Sonesta Harbor Court Hotel in Baltimore’s Inner Harbor. The program begins with a Welcome Reception on Wednesday evening, September 7. The scientific sessions are scheduled on Thursday, Friday, and Saturday, September 8-10. There is a reception – sponsored by PRMS – planned for Thursday evening at the Rusty Scupper Restaurant, which has an amazing view of the Inner Harbor and wonderful food. This will be a great time to connect with colleagues. The program concludes on Saturday evening with a not-to-miss Farewell Dinner Gala which will include live jazz music, performed by Sac Au Lait.

The Southern has a number of important events coming up in the near future. We are planning a virtual social event on Tuesday, June 28 at 7 p.m. Central/8 p.m. Eastern. This will be an opportunity to catch up and socialize with other members. Our annual meeting will be in Baltimore Wednesday, September 7 through Saturday evening, September 10, 2022, at the Royal Sonesta Harbor Court Hotel at the Inner Harbor. The program committee has prepared a wonderful slate of presentations.

Please reach out if you have any questions or need additional information. Looking forward to seeing you at the meeting in September! REPORT from the APA Assembly By: Mark Wright, MD

Some of you may recall my interest in the history of Medicine and Psychiatry. For this year’s meeting I have prepared a presentation on the life, art, and madness of Vincent Van Gogh. I look forward to presenting it to you. I am also interested in your ideas to promote and improve the Southern, preparing us for the future. Many medical societies have had to regroup during COVID, coping with the pandemic and its many challenges, while continuing to provide opportunities for the membership and the profession.

From May 19 to 22, The APA Assembly met in New Orleans in conjunction with its Annual Meeting. I had the privilege to represent the Southern as its delegate for the first time. This was the first time the Assembly met in person since 2019, due to the pandemic. Unfortunately, several delegates had to be out, due to having contracted Covid 19 just prior to the meeting. There were fewer action papers this year compared to recent years, probably due to the transition back to live meetings.

I look forward to seeing you in Baltimore! Executive Director Update By: Janet Bryan

Many of the Action Papers were accepted on the Consent Calendar after being reviewed by the Reference Committees. It greatly streamlined the work and allowed discussion to take place on the more complicated papers.

Happy Summer! It was great to see so many members in New Orleans at the APA meeting in May. The reception with

The consent calendar included: • Bolstering Services for Substance Abuse in Incarcerated Persons • Enhancing the Learning Experience of Residents regarding Jail and Prison Psychiatry • Establishment of an Assembly Committee on Social Determinants of Mental Health • Creating a Curriculum on Climate and Mental Health • Improved Awareness of the Impact of Psychiatric Diagnoses and Treatment on Military Members

states that have passed bills with funding are Colorado, Nevada, Washington and Virginia. Some others have passed laws that provide implementation, but not funding: Illinois, Oregon, Utah, Indiana and West Virginia. Other states have set up committees to study what to do. Surely, all the rest of the southern states could at least get study committees going this next legislative year! The telecommunication companies who have been lobbying against 988 have been the main obstacles. The plan is that the 988 hot line will be staffed with behavioral health workers. Issues that can’t be resolved by a phone call are to be referred to a mobile crisis team that can meet with the caller. If the mobile crisis team determines that further care is needed, the person who had initially called the hotline would be taken to a receiving center for a possible 23-hour voluntary hold for stabilization.

Two issues were particularly interesting. One was recognizing the National Board of Physicians and Surgeons as a Board Certification organization that would be equivalent to the American Board of Psychiatry and Neurology. One benefit is that the NBPS does not require diplomates to take exams every 10 years. John Shemo, MD, of Virginia presented a paper that was very enlightening for many of us regarding Medicare Advantage Plans and the harm they can bring to our patients. The paper was passed, recommending the establishment of a Work Group to formulate an APA position statement concerning the negative consequences that can occur.

Each state is responsible for funding, but some federal dollars are trickling in to set up the call line and to arrange for mobile crisis response, and crisis stabilization. Under the American Rescue Plan, states have the option to support crisis units with Medicaid dollars. The State Mental Health Program Directors for the APA have developed model state legislation: https://www.nasmhpd.org/sites/default/files/FINAL_988_ Model_Bill_2-22-22_edited.pdf

In addition, the Area V Council of the Assembly, which represents most of the southern states, plans to combine its Fall Meeting with the SPA Annual Meeting in Baltimore in September. I believe this will provide us with an opportunity to engage with some new members who are leaders and role models.

This is an attempt to address our national mental health crisis. It reminds me of the establishment of community mental health centers in the 1960s. It will hopefully decrease the number of arrests and eliminate the “boarding” of patients in emergency departments. It may relieve some of the burden on our criminal justice system as well as reduce some of the stigma associated with mental disorders. It may even help decrease the number of mentally ill people who get shot by police. It hopefully will make access to the system more likely as patients and family members will be able to “strike while the iron is hot”.

I have established a separate email account to be used for Assembly business that can be easily accessed by Janet Bryan, our Executive Director, and can continue with my successor when the time comes. That address is listed below. The Assembly will next meet, virtually, in November. Any members who would like to have me bring an issue to the Assembly can contact me at the email below: SPAassemblyrep@gmail.com

There is also a large equity issue in the 988 project. If successfully implemented, persons will be able to call for assistance when they need to call – even in poor areas and in those poorly-served by broadband. It may do more to address the system-wide social inequities than any other effort that I know of other than alleviating poverty itself.

CALL 988! A New System for Getting Help for People in Crisis By: Jenny L. Boyer, MD APA Area V Trustee

My hope is that our District Branches in the South – in partnership with the APA – will shine in making this new system a success. I think the Legislative Chair for each state Psychiatric Association should reach out to the Chair of the State Medical Association’s Legislative Committee and propose that legislation for 988 be introduced in the next session. We then ask our friends on both sides of the aisle in the state legislature to vote for it. Issues of mental health do not respect “political party lines”.

Everyone knows that Covid brought mental health issues to the forefront. As a result of all this trouble, we will soon have access to a new hot line. At least something good came out of COVID! The National Suicide Hotline designation Act passed in 2020. The number “988” is supposed to become the “hot line” on July 16, 2022. The states will need to share the financing for implementation along with the feds. The only

diagnoses, insurance coverage, etc.? “Agitated” or “poor judgment” are not ICD-10 labels. Minor diagnoses don't work to justify admission, and after all, we’re not always clear about whether someone might be bipolar, are we? We don’t think they have schizophrenia and that might be more difficult to realistically establish, but they could have bipolar disorder, couldn’t they? So that person gets the label “bipolar disorder” and perhaps gets put on quetiapine (it generally will quiet someone down), and sent upstairs, and insurance will not question paying for the services, and everyone is safe, right?

In my state of Oklahoma, NAMI-OK has taken the lead for getting this legislation passed and has identified a sponsor for 2023. Woo hoo! The Growing Promiscuity of “Bipolar Disorder” By: William Greenberg, MD No, I am not referring to individuals who may be sexually overactive in manic episodes. I am instead speaking of how our professional colleagues are using this diagnosis promiscuously. The alternative explanation would be that there has been an extraordinary increase in the prevalence of this disorder in recent decades, as evidenced by its overly frequent appearance in the discharge summaries I see.

This situation reminds me of what I was seeing in the early 1990s in a county hospital providing a substantial proportion of the acute psychiatric care for a large population. Many individuals were being diagnosed with adjustment disorder, and the county hospital was seeing most of the psychiatric admissions, so repeat admissions could be easily tracked over the course of years. “Adjustment disorder” was very frequently being used as a non-stigmatizing and acceptable provisional diagnosis to justify treatment in that era, but it was not a particularly stable diagnosis over time. It was, in other words, not a label that had any firm biological foundation (and how many of our psychiatric diagnoses do, after all?). It certainly had some descriptive value, and implied that a more serious mental disorder was not appreciated at that time. But, principally, it was an accepted label to justify treatment, including psychiatric admission, if other facts supported its seriousness. Since this was a retrospective chart review, the methodology was not tight, but it did get published in the American Journal of Psychiatry, and it is still often cited. I think this has been because it was not full of jargon, and we were not talking about idealized diagnoses, but rather we were looking at how we were handling real-life patients in common treatment settings.

I don’t think this is just a matter of where I am currently working. I have seen it in other venues where I have worked in recent years. I am currently practicing telepsychiatry for a state prison system, where inmates identified as having a need for mental health services are screened and treated. Simply being arrested, sent to prison and coping with all that it entails is stressful, and most of the individuals I see would be most properly described as having an “adjustment disorder” of one sort or another, generally along with one or more substance use disorders. Traumarelated disorders are also common. However, most of these patients “explain” to me that they have bipolar disorder (and often other psychiatric diagnoses). They almost universally respond affirmatively if I ask if that means they could be feeling strongly one way and then a few minutes later feel much differently, and this that this goes on frequently – often many times in a day. Some already have Social Security Disability Income, and protecting this status with bipolar labeling represent secondary gain. “Bipolar” has also become a popular label that people may employ for someone whose mood can shift visibly and suddenly, just as “OCD” can be informally used to describe anyone who is very diligent about some task. I see prison patients who have bipolar disorder, although, ironically, they are more likely to reject that label.

I think things have gotten worse. “Bipolar Disorder” can help get someone admitted, and perhaps committed, but if used promiscuously, it can lead patients to have serious misconceptions about themselves, and often experience long-term side effects from medications they had not needed. Moreover, it is important that patients learn more about how to understand their emotions and their behavioral responses, and how to manage their feeling states and behaviors, without believing that everything needs to be addressed with a psychoactive substance, prescribed or otherwise obtained. This phenomenon of over-diagnosing individuals with bipolar disorder also represents the misapplication of our current corporate for-profit managerial mindset, abetted by check boxes and rating scales and metrics. I believe it is a seriously misplaced application of scientific principles when it comes to Psychiatry and mental health in general. Cognitive-behavioral therapy, dialectic behavioral therapy and 12-step programs and such do have real utility for those who will buy in to those programs reliably and consistently. These indeed are valid ways to address human suffering, as is psychopharmacology. What is often missing in our current managed care system is an

Something more than incompetent diagnosing has been driving this phenomenon. And that is that willful inaccuracy helps get someone treated and the treatment paid for. Patients are seen in an emergency department, often agitated and in poor control. Perhaps they were using too much methamphetamine, or a mixture of things, but one senses that they are in trouble and ought to be confined and treated. Perhaps they are also homeless, perhaps withdrawing, perhaps having acute and serious conflicts with others. How does this fit in with our modern practice of relying on cost containment, guidelines,

adequate appreciation of the need for the more personal and individualized, humanistic approach to our patients and their problems. We should not just fill in all the check boxes, put someone in one of our simplistic diagnostic categories and apply statistical guidelines to replace reasonable individualized clinical judgment. The current epidemic of bipolar disorder labeling is only one aspect of this larger problem.

walking me through life-saving measures, until EMS burst through the doors. “You’re in good hands now. Hang in there,” he said as the line went dead. The EMT was rather blunt, “I’m not gonna lie to you, Sir. She’s in really bad shape. We will do our best.” “I know. I’m a doctor,” I replied as I took a deep breath and started to sob for the first time. It took two EMTs and three firefighters to bring Mami down from our third-floor walkup. As I ran towards my car to follow the ambulance for the less than one-half mile to the ER across the street, the same no-nonsense EMT yelled, “You’re a physician. You ride with us, Doc!”

Behind the Curtain: My Family’s Ordeal as Healthcare Consumers By: Felix Torres, MD

And so started our family’s ordeal behind the curtain of healthcare. I was about to have a front-row seat to what our patients go through as healthcare consumers. And it was not pretty.

February 11, 2022: What started as an idyllic midwinter Texas day was about to turn into a midwinter night’s nightmare. With COVID-19 easing up, I was to leave early that morning to attend my first in-person conference in over two years. As I readied myself in the guest bathroom, trying to minimize noise and avoid waking up our almost two-year-old twins at 6 a.m. in the morning, I could hear my mother, Mami, snoring in her room. I was overjoyed, as she had been experiencing insomnia in the previous weeks. I went about my day blissfully, oblivious of what lay ahead.

In the bustling and loud ER and with my mask on, the clerk could not hear me well enough to get Mami’s identifying information and find her established chart. With no time to waste, the clerk told me, “Let’s just do a trauma chart; it can be merged with her regular chart later.” And so she became Northdakota, Zxy. I am not one to believe in signs, but how fortuitous was it that her trauma last name was the same as the state of our twins’ birth by gestational carrier? It had to be a good sign. Mami was intubated in the ER. She was admitted to the ICU with a presumptive diagnosis of urosepsis. She had basically gone from having a silent urinary tract infection to being septic overnight. My sister arrived the next day, and we alternated long hours at the bedside. Because of COVID, only one unique visitor was allowed per day, but medical staff thankfully turned a blind eye and let us spend as much time together as we wanted. We have all heard how important it is for family to be at bedside in cases like these – an understatement! Without us by her side, alarm bells would have gone unattended. Without us as her voice making her needs known for those long weeks in the ICU, I wonder if she would still be around. Mami has the strongest will to live. She is a fighter. But I do not know if she would have survived without us by her side. Not only for support, but also as careful watchdogs over her care. Mami’s chart was never merged during her stay (per hospital IT policies that only happens at discharge). Reading the notes every night as I struggled to fall asleep, I was witness to the countless inaccuracies stemming from failure to review her regular medical chart. History of COVID, lung excision due to lung cancer, history of diabetes, and no known drug allergies were only a few of the several inaccuracies. And those inaccuracies were never corrected even after I repeatedly raised them to her care team. As the anesthesia and ENT teams performed a pre-tracheostomy placement timeout two weeks into her hospitalization, I heard them regurgitate all these charting errors. I lost it when I heard, “no known drug allergies.” She actually has 7, mostly antibiotics. How many near-misses took place! Almost-sentinel events had we not been bedside to jump on the staff and correct them.

At close to 2 p.m., I received a text from my husband letting me know that Mami had not yet come out of her room for breakfast. I jokingly wrote back what I now regret, “Check in on her and make sure she's not dead.” (I do have a rather dark sense of humor.) In a room darkened by blackout shades, my husband peaked, listened, and texted me back: “She’s snoring like a freight train.” I replied, “Let her sleep, she’s been through a lot recently.” Mami in fact had been through several stressors since we plucked her away from California, where she loved to live, but could no longer do it independently. Add to that the loss of three of her sisters and the inability to travel to Puerto Rico for funerals, an important part of the grieving process, because of the COVID pandemic and the fact that she was born with only one lung. I arrived at home around 7 p.m., stripping my clothes in the laundry room and heading straight to the shower to decontaminate. Refreshed and with the dinner table ready, I knocked on Mami’s door … but there was no answer. The sun had already set, and the room was pitch dark. Lights off, I sat at the foot of the bed, giving her a slight nudge on her left calf. Nothing. I walked towards the light switch. As I turned around towards her, the most ominous sight emerged under the slow-to-warm-up energy-saving lightbulb. Eyes bulging out. Ashen. Rapid, shallow breathing. Unresponsive. No muscle tone. “Oh my God! She’s dying! Call 911!”, I screamed. Her regularly irregular pulse, her skin tone, and her agonal breathing were all signs that time was of the essence. But time was slow to pass. The 30 minutes it took for EMS to arrive seemed like an eternity. All my medical training was failing me as I saw Mami fade away in front of me. The kind and calm voice of the 911 operator stayed with me,

Mami, thankfully, tolerated the tracheostomy placement, and the ICU pulmonary team aggressively worked towards weaning her off the ventilator. With numbers looking better and better, case management came along, pushing the discharge. We were sold on this “amazing” long-term acute care hospital (LTACH) whose sole purpose was to “provide intense physical and pulmonary rehab” and to work towards weaning her off the vent “in less than three weeks.” The largest disappointment and worst medical care were about to ensue. We eagerly arrived at the facility, only to return to the ICU one week later. The care at the LTACH left much to be desired. They were not even trying with her! Mami went from getting daily physical therapy, sitting in a chair for 4 hours, 12 hours on CPAP with minimal mechanical ventilation, getting repositioned in bed every two hours, and being bathed once daily when in the ICU – to sporadic physical therapy, sitting in a chair for an hour if that, 23 hours on full ventilator settings, getting repositioned twice a day, and being bathed every other day! Add to that THREE hospital-acquired bacteria in six days and all her previous clinical gains fizzled! She was now in worse shape than when she arrived. As we walked the halls of the LTACH on Mami’s transfer back to the ICU, I felt saddened, peeking into room after room of poor souls with no visitors and no one to advocate for them. I wonder how (and if) they are today…

A Remarkable Woman A Reformer for the Ages By: Steven S. Sharfstein, MD Dorothea Dix (1802-1887) was the most remarkable single-citizen reformer in the history of this country. She sponsored and drafted legislation that led to the construction of psychiatric institutions around the country over nearly 40 years. Her work led to 38 asylums (not a bad word in the day) being founded in 18 states, as well as others in Canada, UK and Europe. She thrust “insanity” or mental illness into the center of public policy debate in the U.S. She held that it was the obligation of the state to provide decent help to those who could not care for themselves due to severe mental illness. In colonial America, the indigent insane were lumped together with a broad class of “deviants” – beggars, vagrants, petty criminals, the chronically ill, and the aged. They were managed by their families, if they were better off, or were in jails or almshouses or were homeless. After Dorothea Dix, the insane became a special class of beings who needed special treatment in a special kind of hospital – the asylum.

Three weeks after her return to the ICU and 56 days after that fateful night when she was almost gone, Mami returned home. Another LTACH had been recommended, but we did not dare subject her to that again! She developed severe tracheomalacia, likely from the trach, and three nosocomial respiratory infections, so she has a tracheostomy tube for the long haul. We have needed to make several adjustments to care for her at home: Home physical therapy. Assisting her with bathing. Hospital bed. Oxygen concentrator. BiPAP machine. Humidifier. Nebulizer. Suction machine. Oxygen tanks. Trach care supplies. A go-bag for emergencies. A discontinued, yet extremely helpful Echo Button by her bedside which, when pressed, announces throughout all the Alexa devices at home, “Mami needs help!” We begrudgingly, yet successfully, navigated the inpatient and subacute medical care worlds. We are now tackling two different beasts – durable medical equipment and home care companies. And to think that last December Mami was questioning whether to drop her Medicare supplement insurance plan. Glad I convinced her to keep it!

In 1841 she was teaching Sunday school in the Middlesex County jail in Cambridge, MA, in the dead of winter and there was no heat. When she complained to the jailer, he responded “Madam, the insane require no heat”. At age 40 she realized that this was to be her calling. She went to the legislature and obtained an official inspection commission that led to heating in the jail. Thus began her prodigious campaign that transformed the treatment of mental illness. She visited towns and villages, inspecting almshouses, jails, and private homes. She took copious notes and made striking observations in her report. This “Memorial” and others were an amalgam of public health – facts and numbers – and vivid descriptions of the conditions she found. These Memorials combined humanitarianism and religious imagery. She provided tours of hell on earth – vivid tableaux of cruelty and neglect. She collected immense data, not only on the individuals and conditions, but also on such details as the measurement of the rooms/cells she found and how people were dressed and what they ate. Most importantly, she described her moral affront and emotional reactions. She was able to render the unthinkable in terms that were believable.

I have been fortunate to be involved in Mami’s care, having the medical knowledge to ask the right questions and, at times, not mentioning I was a physician to see how far the hogwash would go. Caretaker burnout is real, and I am fortunate to have the support of my husband and my sister. This experience has been a sad reminder of what our patients go through in our country’s complicated and largely inefficient healthcare system. I have seen behind the curtain, and I can honestly say, “There’s no place like home!” Dorothea Dix

Her presentation of her Memorial to the legislators in Massachusetts, as well as the stories about her work in newspapers, persuaded them to allocate funds for the expansion of the Worcester Asylum and the building and staffing of additional asylums. This was her model: study and survey, make a dramatic presentation, advocate for funds, then follow through for constructing asylums. Over the next decade she visited 13 states in pursuit of her mission.

Her last survey and Memorial were in Maryland in 1851. During the 1830s, even before she had launched her onewoman crusade, and the 1840s, she had made dozens of trips to Baltimore, staying with the prominent Unitarian minister, George Washington Burnap. His close friend was Moses Sheppard, a wealthy Quaker and leader in the Friends Meeting. Over many years they corresponded about the wish to build a private asylum modeled on the York Retreat in England, an 18th century Quaker institution that revolutionized hospital psychiatry by providing “moral treatment”. This included humane care with lack of restraints and occupational therapies, instead of the shackles and bloodletting that were common in those times.

Deinstitutionalization, beginning in the 1950s, depopulated the large state hospitals. Many, initially founded as a result of Dix’s advocacy, have closed. One wonders what she would say about the many homeless and incarcerated people who are seriously mentally ill who are getting sub-standard, or no, care in our cities and towns today. Interview: Mark Wright MD SPA Rep to the APA Assembly New Orleans—May 22, 2022 By: Bruce Hershfield, MD Q: “Congratulations on becoming our new APA Assembly Rep. How did the meeting go and what are your plans as our new Rep?”

In her Memorial and petition to the Maryland General Assembly she reviewed the history of care for the insane: the establishment of a public hospital in Baltimore in 1797 that evolved into the Maryland Hospital, the Sisters of Charity Mt. Hope Hospital, and the Baltimore almshouse and penitentiary. She surmised that these institutions were inadequate, with the rate of insanity increasing in the state. Comparing the Census of 1840 with 1850, she noted that the general population increased 24% while the population of the insane jumped 72%. She stressed the importance of early institutionalization to “cure” insanity in young people. She also stressed the importance of rendering comfort for the “incurable”. Because she found that the costs were of great concern to the delegates, she devoted 1/3 of her Memorial to economy. She argued that the economics of a well-managed asylum would prove to be cost-effective and reduce the state’s funding burden, as more of the insane would be “restored to useful employment”. She was successful in getting a $100,000 appropriation over several years that eventually led to the construction and staffing of what became Spring Grove Hospital in Catonsville. She was aided by the strong support of Moses Sheppard.

Dr. W: “I think the meeting that just ended went well. It was my first Assembly meeting as the Rep from the Southern, but I spent the last 20 years as a Rep from Kentucky, so I knew how the Assembly operated. This year was very different because it was much more streamlined and most things were accepted by way of the Consent Calendar instead of being discussed in Reference Committees and then on the floor. My plan is to solicit from our members any issues that they would like to see brought forward to the Assembly. Then we could bring forth some Action Papers that would be applicable to the Southern. I have established a special e-mail address for this that I’ve shared with Janet so people can communicate with me about their concerns, and it’s also the account the APA will use for me in my role in the Assembly. I have been attending the Area V Council meetings, and I plan to attend the SPA Council meetings, too.” Q: “In what way can the Southern communicate better with Area V and Area III?”

So in Maryland, Dorothea Dix not only expanded asylum care at public expense, but also was an important influence on Moses Sheppard and his bequest of $571,441.41 and the founding of the Sheppard Asylum, which was chartered in 1853.

Dr. W: “Area V voted yesterday that its interim meeting in the fall will be in conjunction with the meeting the SPA and Maryland will be having in Baltimore. All we need now is for the APA office to approve where the Area V Council plans to meet.” Q: “What have been the highlights of your time in the Assembly and what have you learned from being in it for 20 years?”

Her Memorials and advocacy led to the founding and construction of 38 asylums, public and private, throughout America. She helped the design, staffing and funding of these institutions. She would make surprise visits (like the Joint Commission today) to inspect them and then challenge the Trustees or the state legislators to implement her findings. Over time, however, due to the pressures of economics as well as a change in the understanding that insanity was chronic and incurable, many of these asylums became mostly custodial in their care of the mentally ill. She was dismayed by these changes, but, aged and frail, she was unable to convince the large state hospitals to provide other than mostlycustodial care.

Dr. W: “I’ve learned that the process moves slowly, but I’ve also learned the importance of camaraderie. The personal connections help to accomplish things. For example, Mary Jo Fitzgerald, who finished as Speaker of the Assembly today, is an SPA member, and her connections with the Southern and with Area V were important in helping her.”

Q: “How did you get involved with organized psychiatry in the first place?”

Q: “What else do you do besides Psychiatry?” Dr. W : “I am a musician. I play the organ and the piano and I sing with the Lexington Chamber Chorale. It’s a group of 25 musicians who have had a professional status at one time or another. We give 5 concerts a year. I used to sing in the Assembly with a quartet. For a while we had 5 and we were called ‘The Unassembled Five’. Three of us were here this weekend, and I said if we had known we were all going to be here we could have come up with a song. We may revisit that. We originally included Jerry Lee Lewis, who was a Rep from Iowa. He really was a first cousin of the famous singer with that name.

Dr. W: “When I was a medical student, I was involved with the AMA, and I was president of the West Virginia student section. Then, when I came to Kentucky, I was involved with its medical association and also with the APA Kentucky District Branch, which was then called the Kentucky Psychiatric Association. I got involved with its program committee and then was its Rep for the Residents and then moved on as the Early Career Rep and have continued to be involved. I have been the Chair of the program committee for more than 10 years and also have been president twice.”

I saw Jo-Ellen Ryall from Missouri this weekend. I got involved when we were at the Speaker’s party one year and she was playing the piano and I started singing ‘On the Street Where You Live’. Gary Weinstein introduced me to Jim Nininger, who told me, ‘We need you to sing with us!’”

Q: “How did you become a psychiatrist?” Dr. W: “I was a psychologist who went back to medical school. Like Jenny Boyer, I always intended to go to medical school, but I became a psychologist by accident. I was teaching anatomy and physiology at Marshall University, and I had an undergrad degree in psychology from Virginia. I was basically told that if I would come into the psychology department there that I could finish my degrees for free. I taught introductory psychology classes and then I took a job right out of my internship until I went to medical school. I practiced as a psychologist. Nat Sandler used to say, ‘You are the only psychologist in Kentucky who has the training to prescribe medication!’”

Q: “What plans do you have for the future?” Dr. W: “I am going to continue working. I am thinking of incorporating some physician extenders in my office so I so I can work a little less. I really am looking forward to working for the Southern in the Assembly. So – if people have anything they would like to discuss with me about the Assembly, please let me know.”

Q: “What did you do as a psychologist?” “Provider”: A Problematic Term for Psychiatry By: Jonathan R. Scarff, M.D.

Dr. W: “I worked in a state hospital, at Huntington State Hospital with Dr. Mildred Bateman. That hospital is named after her now. She was the first African-American woman who was the director of the Department of Mental Health for West Virginia. She later returned to the hospital and that was when I worked with her.”

Over several decades, the word “provider” has been increasingly used to refer to doctors and other healthcare professionals. This word should be replaced by more appropriate terminology.

Q: “What do you do as a psychiatrist?” Dr. W: “I have a private practice at Lexington Behavioral Medicine, where I see children and adolescents as well as adults. Until the pandemic, we had many students who were coming through for training. I plan to start reintroducing them to that. We only went back to seeing patients in person on April 15, and It wasn’t much fun for students to sit behind me and watch me talk with patients on the computer. But I am getting calls now for students who want to return.”

“Provider” has an uncertain, but possibly shameful, origin. The Nazi Party devalued and persecuted Jews during the 1930s in all aspects of German life, including the medical establishment. Beginning with female pediatricians, Jewish physicians were designated not as Ardzt (doctor), but as behandler, which has been loosely translated as “provider.” A native German and Professor of German at the University of Kentucky stated this is likely a shortened version of Krankenbehandler, which is best translated as “healthcare provider” or “healthcare practitioner” (H. Hobusch, personal communication, 2022). However, online dictionaries provide alternate translations of “behandler”, such as handler, dentist, therapist, or practitioner, so whether or not this word has a Nazi origin is unclear.

Q: “So what have you learned from the pandemic?” Dr. W: “I was very much opposed to a telemedicine model prior to that. Suddenly, it was all we had. I actually learned the benefits of it. In Kentucky sometimes, people will travel 3 or 4 hours each way to come to your office. If you can save those people – particularly schoolchildren – from all that travel then you really have facilitated their care. There really are no resources for them in the rural areas of Kentucky.”

Additionally, it is inaccurate. It implies a commercial transaction – a “commoditization” of healthcare. It says nothing about the doctor-patient relationship, built on trust and medical ethics. Calling patients “consumers” or

“clients” is equally inaccurate and undermines the doctorpatient relationship. We are more than “providers” of tests, procedures, or medications for patients – we also serve as patient advocates and confidants.

of which was her entitled leave. There are many personal stories of female physicians desperately advocating for 15 minutes every 4 hours to pump milk for their babies because they are separated from them for 24-48 hours during their shifts. I am truly amazed at the resilience of my colleagues who pump while running codes, or during a laparotomy, or while inserting a chest drain.

Finally, it is misleading. When all treatment team members – such as psychologists, social workers, pharmacists, nurse practitioners, resident physicians, or psychiatrists – are called “providers”, patients may assume that they will receive the same level of care from each. It fails to acknowledge the degrees, training, and skill sets of the various team members.

Heroic deeds some might say, but I sense that the medical community is often not supportive of those who take care of children or who give birth during residency. It should not be this hard to do something that the human race depends upon for survival and is a part of a normal life for most of the world. I do not agree with the notion that life must be put on hold until medical school and residency are completed. This spans the majority of the twenties and sometimes thirties of a person’s life – the most fertile years – and could mean the difference between having a family or not.

Just as airline pilots are not referred to as “air transportation providers” and lawyers are not “legal aid providers”, psychiatrists and other clinicians should not be demeaned as mere “providers.” If overarching generic terms are needed, then “clinician”, “health care professional”, or “practitioner” are more appropriate. We went to medical school – not “provider” school – and I have not seen “provider” on anyone’s diploma or certification. We should educate students, colleagues, patients, and administrators about the improper, inaccurate use of this term and encourage appropriate terminology. This can foster respect and improve morale among members of our profession as well as clarify the roles of the other treatment team members.

It's not just the deferral of a hoped-for life. When we defer hope, sometimes we are sacrificing the development of ourselves in the process. The subtle message that we are telling ourselves is that Medicine is more important than children or than our choice to breastfeed – and, really, more important than the whole-ness of ourselves. A great physician is not just a person with great clinical skills and knowledge, but a person with empathy, life experience, and maturity – one who is developing into a complete person. Many developed countries take this more seriously than America does. For example, in the UK, doctors in training are entitled to one year of maternity leave, at least half of which has some form of pay associated with it. It’s a matter of gender equality.

Hope Deferred By: Tina Thomas, M.D. Psychiatrist, Medici Medical Group, former Psychiatry Resident - University of Texas McGovern Medical School, Houston former Psychiatry Extern University of Louisville School of Medicine

I believe there is much at stake when we ignore the biological and psychological needs of physicians who are or want to be parents. June 30th may come and go, but parenting my three boys before and during residency has been one of my biggest joys. It is worth the sacrifice. Whether hope – when deferred – makes the heart sick depends on what you are hoping for.

It is June 30th. A day that Residents everywhere across the USA eagerly anticipate as the culmination of many years of sacrifice, with the completion of residency. For me, it is just another day in my rotation. I am ending a psychiatric residency late due to having had a baby in my third year. I have five weeks left until I can feel that wonderful sense of achievement that June 30th usually brings. I am not sorry. I would not have done it any other way.

The APA Board’s Structural Racism Accountability Committee: Slowly Moving the Needle By: Felix Torres, MD Minority/Underrepresented Trustee, APA Board

However, having a baby during residency is not for the faint of heart. I have found from my many months of scouring the internet and talking with other residents – in search of solidarity – that childbirth and breastfeeding can be a divisive topic in the medical community. I have read stories of residents, male and female, being advised that they should not have children during medical school and training. It is inconsiderate to other residents if you are having extended “time off.” One male resident is not sure he will be able to attend the birth of his first child if he is in the OR (as an anesthesiology resident) when his wife goes into labor. A female resident is required to work three months extra because she took 10 weeks off, most

Established by the APA Board of Trustees in May, 2021, the Structural Racism Accountability Committee (SRAC) consists of Board members who are responsible to ensure that the 18 recommendations of the 2020-2021 Presidential Task Force on Structural Racism Throughout Psychiatry (TFSR) are carried out, evaluate their success, make recommendations for improvements, and accomplish other listed objectives.

Several of TFSR recommended actions used the term “URM” but no definition of URM exists within the APA’s policies and procedures. Another SRAC recommendation has been the formation of an advisory group, to include members, and the DDHE and the Department of Research, to formally review current nomenclature and make recommendations for future definition/revisions. An environmental scan of several medical organizations and how they define underrepresented groups or participants has been completed by DDHE and will be used by the future advisory group to jumpstart the work.

I was pleased that APA President Vivian B. Pender, MD appointed me and that Mary Roessel, MD and I were approved by the Board to co-chair the SRAC. Other BOT members on the Committee during its first year have been: Drs. Elie Aoun,, Ken Certa, Jeffrey Geller, Glenn Martin, Urooj Yazdani, and Mindy Young. Past APA President Altha Stewart, MD, has served as a consultant. We are dedicated to seeing the work of the TFSR disseminated across the APA, highlighting our commitment to diversity, equity, inclusion, and antiracism (DEI/AR).

As collaboration across the APA and its components is crucial to dismantling structural racism and advancing DEI within our organization and our profession, other SRAC recommendations approved by the APA BOT include:

During its first year, our Committee has been gathering the necessary information to evaluate progress on the TFSR actions approved by the BOT. Early in the process, the Committee decided the most efficient manner to tackle the task assigned to us was to classify the actions into three categories that appeared central in the TFSR’s recommendations:

• •

1) Database: There were clear needs to tap into our database, to improve the database definitions and data collection processes, and to be able to effectuate the necessary change. 2) Mentorship, for those actions requiring efforts to develop and sustain mentorship initiatives. 3) Structural, for those actions requiring a revision in the APA Bylaws, the Operations Manual of the BOT and Assembly, and/or the Procedural Code of the Assembly.

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Requiring that various APA components, to include the Joint Reference Committee, invite SRAC to participate in discussions on implementing DEI/AR activities. Requesting that various APA components, to include the Assembly Executive Committee and Area Councils, invite SRAC to participate in discussions on implementing these activities. Requesting that the APA Administration provide an analysis of whether the adoption of term limits for Council chairpersons and for other Council members has adversely affected M/UR representation, due to long-involved M/UR psychiatrists terming out in 2021.

Yet another challenge identified by the SRAC has been the issue of self-identification. Accurate and comprehensive data on the APA’s membership’s race, ethnicity, gender, and other demographic information is imperative to address DEI/AR issues and improve the member experience. In collaboration with the SRAC, APA Communications is unveiling the “I Checked the Box” campaign, aimed at encouraging APA members to selfidentify in the membership database. The campaign is employing well-respected BIPOC leaders within the organization to encourage self-identification and provide education on its importance.

SRAC members then volunteered to follow up on approved action items and report on: a) status/implementation of action item, b) metrics to evaluate impact/success, c) accountability plan, d) sustainability plan, and e) any recommendations to improve success. As SRAC members started our outreach to APA staff, Components, and Assembly leadership to collect the necessary information, our inquiries were met with confusion and resistance. Improved communication at all levels was required for stakeholders to understand the charge and scope of the SRAC. Accountability and sustainability were not possible without action and commitment to addressing structural issues within the APA. We recommended clear and transparent communication between the BOT and all APA components, leadership and our membership at large, about the work entrusted to us. This has been accomplished through SRAC collaboration with APA Communications, APA Marketing and the Division of Diversity and Health Equity (DDHE) and the consolidation of all matters pertaining to DEI/AR under one location on the APA website.

While the work of the SRAC may have only moved the needle slightly during our first year, our efforts have been steady and unflinching. We look forward to year two! For more information on the SRAC, including reports to the APA BOT and other DEI/AR resources, please visit https://www.psychiatry.org/psychiatrists/diversity/govern ance/structural-racism-accountability-committee

Southeast Asian female patient I treated in the UK. She needed involuntary inpatient psychiatric care, but because of fear of how this would affect her future, her family wanted to take her home, promising me that they would lock her in her room. This was their expression of care for their daughter but was at odds with the need to protect her rights and autonomy. Though an involuntary admission was also against her autonomy, legally there were safeguards to protect her in the hospital. But this made no sense to her family. I understood why they felt that way. Many cultural factors were at play: stigma, mistrust, and the conflict between a paternalistic, collectivist world view and an individualistic culture.

South Asians: A “Forgotten Minority” By: Tina Thomas, M.D., MRCPsych Houston, Texas (previously, a psychiatry department observer-physician at the University of Louisville) Immigrants from South Asia represent the fastest-growing Asian-American subgroup. They are a heterogenous group of people with diverse language, religion, and cultural belief systems. That presents a challenge to providing them with culturally competent medical care. The literature could show a greater appreciation of this minority experience. About 90% of medical papers are written by authors trained and affiliated with a Eurocentric outlook – intrapsychically-oriented and individualistic – leaving 10% from non-Western origins. This has been referred to as the “10/90 divide”. Published research regarding South Asian psychiatric issues is also small. This can lead to unconscious implicit bias, as well as conscious discrimination when treating South Asian patients.

Most Western cultures are individualistic, while the South Asian is more collectivist. As a child, I was told by my grandfather, “The first thing you are is your father’s daughter.” In this view, what the child becomes reflects very personally on the father. This sense of belonging to your family confers a sense of responsibility on the parents and family, not just the child. The South Asian parental dictation of a child’s life represents its sense of duty to fulfill the responsibility it owes the child. To be successful, married, and to have children not only reflects highly on the family, but makes the attainment of these goals its responsibility. This patient’s family clearly felt it was unnatural to relinquish what they felt was its responsibility for the child onto a psychiatric facility. It is important to appreciate these tensions so that the families’ choices do not appear to be simply intrusive.

As a South Asian psychiatrist from the UK who is now living in the USA, I recently had the opportunity to reflect on my own cultural experiences. I was providing psychotherapy to a young woman who herself was from this population. Growing up in London, I had listened to my Indian parents tell stories of their acculturation to the UK. I was fascinated by their resilience, successes, and failures. This fostered a desire to understand how culture impacts individuals. What impact does culture have on self-identity, belonging, success and mental health?

Treating patients from cultures that are not familiar to us requires us to examine our own biases and judgments. These often have been heavily influenced by our own cultural exposures. We must also understand that bicultural individuals must contend with opposing messages as they develop their values and beliefs. This patient also felt she had to graduate from college, due to parental pressure. The Southeast Asian culture views education highly and exploration of this is less tolerated than in the West. My patient had to develop a sense of what she believed was right as she straddled both cultures and made decisions. In treating her, I had to understand why this caused internal conflict. Being sensitive to these various dilemmas is an important part of treatment.

I recognized familiar aspects of my own background in my patient: the importance of academic achievement, prominent parental roles, emphasis on community, and pressures to maintain cultural fidelity. I could understand the conflict between Southeast Asian culture and Western ideology in contributing to her current struggles; similarly, I recognized the resilience she possessed. I also knew that her subculture was very different from mine, and there was much I needed to learn from her. She struggled with a difficulty in identity formation that affected her sense of belonging. She had a constant sense of being the “other.” She was not “at one” with her family, nor fully accepted into the culture of her American friends. Her experience matched the concept of occupying a “third culture”: people who have spent much of their childhood outside of the culture of their parents. This term frequently describes children living abroad but can be applied to second-generation persons. This leaves some people without a clear sense of belonging or with a sense of multiple belongings.

The language of illness also varies among cultures. Somatization is well documented in Asian communities and has been linked to stigma. Mental distress can be reflected in somatic expressions of illness. In Southeast Asian culture, physical illness is more acceptable and solicits love and sympathy, while mental illness may signify weakness and shame. My patient would communicate to her parents on a more somatic level. Listening to how patients communicate their symptoms and expanding their ability to express their psychological needs can empower them to better understand the mindbody connection.

There are many potential conflicts in the treatment of patients with this multicultural identity. I experienced one such tension in the family of another college-age

My experience with patients from South Asia has caused me to reflect on my own multi-cultural identity. It gave me the sense that “being different” or “not belonging” can increase cognitive flexibility, intercultural fluency, and self-efficacy. This kind of work presents challenges, but it has the potential to resolve dissonant experiences. Treatment with a culturally sensitive provider is an opportunity for both the patient and the therapist.

the degree (if any) and duration of immunity is not known. The risk for infection escalates with any immunocompromising conditions, including pregnancy, lactation, age extremes, and/or suboptimal health status. Whenever confronting someone who might have contracted it, immediately quarantine and institute infection precautions. Immediately contact the Infectious disease medical team. Hydration and routine medical attention must be assured. Provide protective gear as soon as possible. Laboratory testing can confirm the diagnosis.

I believe we can all use our own personal experiences and interactions with culture to address the issues that many members of minorities face. We can use our own stories to connect with patients. We are not just passive recipients of the effects of culture, and the lessons we learn when we reflect on our own experiences can benefit our patients and ourselves.

What about treatment? Antiviral drugs already approved for patients with smallpox may have efficacy for patients with monkeypox. One of them, tecovirimat, is the most prominent current intervention – but it is only provided on a compassionateneeds basis. Other antiviral agents, like cidofovir are considered, as are infusions of vaccinia immunoglobulins.

Monkeypox 101: What a Psychiatrist Should Know By: Steven Lippmann, M.D.

If we are aware of the risk and know what to do, we can do our part to make our patients and our communities safer.

Monkeypox has arrived. Help! This viral disease was first recognized in African animals during the 1950s and was also observed in humans in 1970. It is now spreading worldwide, including to the USA. You might see a case. What to do?

Oral Anti-Coronavirus Pharmacotherapy? Yes, nirmatrelvir and ritonavir under the name Paxlovid By: Aya Allam, M.D., University of Menoufia Faculty of Medicine, Menoufia, Egypt & Steven Lippmann, M.D.

Think about monkeypox nowadays whenever you see someone with a viral illness and a rash. Suspicion is elevated by a viral-like prodrome in someone who had contact with a potential monkeypox case in a person or animal. A usually painful cutaneous eruption starts on the face or mouth, spreads elsewhere, can be focal (as in groin only), and might include palms and soles (unlike most other conditions). Lesions proceed from macular to papular, then vesicular, and finally to pustules that eventually crust over and fade. Once healed, contagion is unlikely.

We finally have an expanding selection of effective vaccines for this pandemic. These are preventive pharmaceuticals that are available and effective at attenuating serious disease, hospitalization, and death. Lots of people have been vaccinated, but many have not – or have refused it. For a wide variety of reasons some individuals will not, or should not, be immunized. There also are those who do not or cannot mount a robust response to vaccines. What to do?

Transmission and infection can occur from bodily contact, including respiratory secretions. It appears to be commonly associated with men who have sexual involvement with men or with other close contacts and might also be contagious by touching fomites. Air-borne transmission is possible too. Incubation is about 1-2 weeks. The usual symptoms are fever, malaise, weakness, fatigue, myalgias, headache, and sometimes a sore throat or cough. Some people remain asymptomatic. Lymphadenopathy is a prominent feature and distinguishes monkeypox from smallpox. Cases range from being mild and self-limited, to a dangerous disease that requires hospitalization and treatment. The course of illness often lasts three weeks. Mortality may approach 10%.

The most popular answer is to get fully vaccinated and boosted. Instituting routine self-care, keeping a healthy weight, and getting appropriate medical attention can also help. A balanced diet (zinc included), regular exercise, having sunlight exposure or supplemental vitamin D, and getting enough sleep are important. If infection occurs, several antiviral and monoclonal antibody therapies are also becoming available. Antiviral medications are in the news. The combination of nirmatrelvir and ritonavir has just been approved. Taken by someone very early in the course of infection, it can attenuate serious COVID-19 disease. Developed and marketed by Pfizer under the “Paxlovid” name, it works at the host’s intracellular level. The U.S.A. government is

Monkeypox is in the orthopox genus, together with variola (smallpox), vaccinia, and cowpox. Smallpox vaccination might provide protection against monkeypox; however,

purchasing and distributing large quantities of it for prescribing under emergency use guidelines. It comes in a three-pill package of two nirmatrelvir 150mg, and one ritonavir 100mg, tablets. The regimen is for one whole pill pack, twice daily for a five-day course. It should be started during the earliest days of symptomatology, once the diagnosis is confirmed – best within the initial three days. It is still indicated up to the fifth day of symptoms, but not later.

What ? Fluvoxamine Is An Anti-COVID-19 Drug ? By: Omar Elsayed, M.D., Ahmad Sleem, M.D., Ali Farooqui, M.D. & Steven Lippmann, M.D. – University of Louisville

The good news: When nirmatrelvir/ritonavir is utilized within the five-day period, hospital admissions, serious illness, and death are reduced 88% - even better if used within the first three days. Side effects reportedly are minimal but have included altered gustatory sensation and/or diarrhea. It appears to have beneficial action for patients contacting omicron and/or delta variants.

Big news: Fluvoxamine appears to be a treatment to mitigate COVID-19. Yes, this SSRI possesses potential antiviral actions to counter the SARS-CoV-2 virus. COVID-19 has gravely impacted human life, with emerging new variants causing record morbidity and mortality worldwide. There are several pharmaceutical remedies to mitigate it, but our scientific and medical systems seek new interventions

Pharmaceutical actions occur within the host cell. Nirmatrelvir is the primary antiviral agent, acting by inactivating SARS-CoV-2 proteases. That disturbs RNA production of virus proteins and diminishes coronavirus replication and reduces the viral load. It has a short duration of action, but ritonavir facilitates it to persist longer in the body, via cytochrome P450 3A4 enzyme action. Ritonavir also can interfere with other medications metabolized via this cytochrome system.

The hyperinflammatory syndrome induced by SARSCoV-2 contributes to COVID-19 severity and mortality. Fluvoxamine stimulates anti-inflammatory action, as a proposed therapeutic mechanism. This occurs via σ-1 receptor (S1R) agonism, at the endoplasmic reticulum and linked to mitochondrial membranes. That normalizes mitochondrial stress and promotes cellular survival. Other potential mechanisms include: anti-platelet properties, decreasing mast cell histamine release, antiviral lysosomotropism, and regulation of stress triggered by a viral infection and the response to its replication. Fluvoxamine, produces the strongest activity at S1R of all SSRIs, and can mitigate the hyper-inflammatory response. This appears to help during less severe COVID-19 illnesses.

Patients must be at least 12 years old and weigh 88 pounds. It is not indicated for patients who are hospitalized, on oxygen therapy, or already have been ill beyond the fifth day of symptomatology. Neither is it indicated for patients with notable pathology in the liver or kidney. Nirmatrelvir/ritonavir does not replace the protective aspect of vaccination. It is not authorized in pre-exposure or post-exposure prophylaxis. It is designed for patients early in a confirmed illness, and especially if they have comorbidities like older age or obesity, or with conditions that elevate risk (e.g., immunological or vascular). It can be administered to a vaccinated, unvaccinated, and/or a reinfected person who has recovered from a previous COVID-19 illness.

Two clinical trials explored that possibility. The first study randomized 152 non-hospitalized adults, with severe acute respiratory syndrome due to SARS-CoV-2 infection at two sites, to receive either 100 mg of fluvoxamine or placebo. Clinical deterioration occurred in 6 participants on placebo as compared to none in the treatment group (8.7% [95%CI, 1.8%-16.4%, p=0.009]). The investigation was limited by its small size, in a restricted geographical area, and because 20% of the subjects stopped responding to treatment.

Nirmatrelvir/ritonavir offers a powerful new option in combating COVID-19. Other antiviral drugs are here; more are likely to come. Because they use a different mode of action, antiviral drugs can be used for administration conjointly with monoclonal antibody therapies. Our healthcare system now has more and better options for combating the pandemic.

The other research was conducted at 11 sites, randomizing 1,497 high-risk, symptomatic adults who tested positive and who were prescribed fluvoxamine 100 mg twice daily for 10 days (or else placebo). The outcome measure was the number of individuals on treatment transferred to or retained in a hospital as compared to those taking a placebo (79 [11%] of 741 vs 119 [16%] of 756 at a relative risk of 0·68; 95% - CI: 0.520.88). Differences in mortality rates were not significant. The study was stopped due to the superior efficacy of fluvoxamine.

Fluvoxamine is an approved, widely available, inexpensive medication with an established safety profile. It appears to offer benefit to patients with SARS-Cov-2 infections at diminishing COVID-19 severity, morbidity, and mortality. It is already promoted for this reason. Clinical and research experience should clarify its utility.

replaced office hours and study group sessions, while iPads served as white boards. While many of my classmates chose to stay home, I and a few other students commuted to campus to tune into class. When it got colder, almost everyone stayed at home. I remember some days in December and January, I was the only person in a building meant for hundreds of students. In-person clinical experiences like shadowing and standardized patient encounters were also limited. Our school creatively worked around this by making our practice patient encounters “telemedicine appointments” on Zoom. We were the first medical school class trained to evaluate patients remotely instead of through physical exam maneuvers. For hospital shadowing, the school purchased Google Glasses that Attendings and Residents wore for us to experience what they were doing on the wards and with their surgical procedures. Before I could make it into the actual O.R., I had already been able to experience surgery through these virtual experiences.

My Experience as a Medical Student in 2020 and during COVID-19 By: Ankita Nair, University of Louisville Medical Student When I got accepted in October, 2019, I had no idea how different the world would be when I would begin school in August, 2020. My interview and school visit took place on a bustling campus, whereas there were days in my first semester when I was the only student in the instructional building. I remember touring the anatomy lab of every medical school I visited, only to, ironically, never step foot in such a room as an actual student.

Overall, COVID-19 forced me and my classmates to learn Medicine through a screen instead of the conventional way used by centuries of students. After returning to inperson learning as a second-year student, I can say that it has been a better experience – although I am grateful, we had the technology to carry on learning in a pandemic. It has been amazing to see my professors and classmates every day, shadow in-person at the hospital, and study in the library – experiences I no longer take for granted.

The COVID-19 pandemic fundamentally changed our society – with social distancing, remote work, and stay-athome orders. Schools and universities shifted instruction to Zoom, hospital ICUs filled up, and many physicians shifted to telemedicine. As I observed all these changes in the months leading up to medical school, I knew my educational experience was going to be different and likely not to be in-person. Despite all this, I was grateful that I was getting the opportunity to study medicine. Amidst all the events that 2020 cancelled, it was relieving that medical school was still happening.

The silver lining of all the obstacles we overcame was finally having our white coat ceremony at the end of the first year. Most ceremonies are held right before students start their first year. However, earning our whitecoats after experiencing such a challenging year felt even more meaningful. I finally got to meet all my classmates!

My school had initially tried a hybrid model, but we went remote within the first 90 days. We used three different videoconferencing platforms including Zoom, Blue Jeans, and Microsoft Teams. All my lectures were pre-recorded, which meant that I would wake up every day with a quota of lectures that I could watch “on-demand” like a form of medical Netflix. In my second semester, my school switched to virtual lectures in real-time, after student feedback. Instead of dissecting cadavers in person, we used software from Visible Body, 4-D Anatomy, and Acland’s video atlas. The virtual format allowed our professors to supplement our curriculum with radiology, where we learned to identify and analyze common disorders on Xray and CT scans. For exams, we took assessments on software that monitored our computer activity and used a secondary device logged into zoom so school proctors could monitor us through the cameras. By the end of our first semester, our class joke was that we were probably the first cohort to be able to attend medical school in pajamas.

Botulinum Toxin Is a Possible Treatment for Major Depression By: Asha M. Mahajan B.S., Ali A. Farooqui, M.D., & Rif El-Mallakh, M.D., University of Louisville Editor’s Note: A version of this article appeared in the Kentucky Psychiatric Medical Association Newsletter, edited by Steven Lippmann, MD Major depressive disorder is the leading cause of disability in the United States for people between the ages of 15 to 44. By 2030, it is estimated that it will be the second most disabling disease burden for everyone.

I had never used Zoom before COVID, so it was a big transition for me. It was also surprising to me, a typical pen and paper learner, how much more technology factored into my day-to-day learning. Chat rooms

Antidepressants are often prescribed for people as a firstline treatment for depression. However, 50% of patients who take them experience side effects, including insomnia, headaches, decreased libido, and – in some cases – suicidal ideation.

anticonvulsant and second-generation drugs that also work.

antipsychotic

It is difficult to decide whether to continue prescribing lithium, once CKD has occurred, since the other medications also have side effects, or can increase the risk of relapse or suicide. Lithium is known as a suicide prevention agent. When does the progressive renal failure outweigh the relapse danger, since few patients develop ESRD and lithium discontinuation may not reverse kidney dysfunction? No guidelines exist.

There is new data for botulinum toxin as a potential way to attenuate depression. Extracted from Clostridium botulinum, it inhibits the release of acetylcholine from entering the neuromuscular junction; that results in temporary paralysis of the affected muscles. It historically has been used for cosmetic indications and for some ailments like migraine. Clinicians began noticing that some patients receiving glabellar injections experienced a decrease in their depressive symptoms.

Monitor serum creatinine and estimated glomerular filtration rate (eGFR) before initiating lithium and subsequently every 3 to 6 months. A significant rise in serum creatinine on more than two occasions or an eGFR < 30 warrants a nephrology consultation. Serum creatinine levels higher than 2.5 mg/dL may be the only reliable predictor of ESRD. A creatinine clearance of 2540 ml/min suggests irreversible renal damage, even after lithium cessation. Low lithium maintenance doses might reduce potential kidney damage; however, many patients depend on higher doses for relapse prevention.

The first study on the effects of botulinum toxin to treat subjects with major depression was conducted in 2006. Participants were 10 women, each with depression severity ranging from moderate to severe. They were administered glabellar botulinum toxin injections and evaluated with the Beck Depression Inventory-II. All improved at two-month follow-up, and nine achieved remission. A meta-analysis of five placebo-controlled studies revealed that administration of botulinum toxin to the glabellar muscles significantly diminished major depressive symptoms within a month.

Some patients rarely evidence ESRD or CKD after even 20 years of lithium. When older people do develop renal impairment, it can be secondary to medical conditions, like hypertension. There is also age-related decline in kidney function. Magnetic resonance imaging (MRI) could be a means for visualizing lithium-induced microcyst nephropathies. These microcysts are bilateral, multiple, symmetrical, and uniformly cortico-medullary at sizes of under 2 mm. When CKD occurs during long-term lithium treatment, MRI findings of these microcysts can help identify lithium as the likely cause.

It is unclear why depression should respond so well to glabellar paralysis. Improvement in appearance is an unlikely cause since animal models of depression also exhibit progress. Facial muscle movements may play a role in regulating the perception of emotions. “Negative” emotions result in contraction of these muscles and may signal a negative emotional state to the brain. Paralysis of these muscles may prevent that feedback. It is more likely that the presynaptic mechanism of botulinum toxin has a wider inhibitory effect on acetylcholine release, thereby impacting the “pro-depressant” effect of excessive cholinergic stimulation.

When deciding whether to continue lithium or not, consider age, family history of kidney disease, response to lithium or other pharmacotherapies, and the risk for relapse if it is stopped. Young persons with a rapid decline of eGFR are more likely to develop renal failure than older ones are. Lithium cessation in stable responders or patients with personal or family histories of prior relapses should be avoided when the therapeutic benefits seem to outweigh the risks of developing ESRD.

There are sufficient data to suggest that botulinum toxin injections can help patients diagnosed with depression. We need additional data to fully understand the efficacy, durability, and mechanism of this treatment. Lithium Nephropathy Prescribing Practices By: Ben Sanders, DO, (University of Kentucky), Ziad Ali, MD (University of Kentucky) & Steven Lippmann, MD (University of Louisville)

An analysis of the benefits and risks of prescribing lithium versus anticonvulsant medicines as maintenance therapy for bipolar disorder patients concluded that most should continue on lithium, despite long-term adverse renal damage. Nephrology referrals should focus on managing the risks of continuing lithium rather than stopping it.

Lithium is an effective treatment for people with bipolar disorders. However, potential risks of long-term lithium therapy – induced chronic kidney disease (CKD) or end stage renal disease (ESRD) have led to prescribing it less often. This has been compounded by the availability of

CKD is rare, and reversibility of impaired kidney function is not assured following lithium cessation. Nephrology referrals generally should assist at managing renal function.

Ketamaine Diminishes Suicidality By: Alex Van, Research Scholar, Medical University of the Americas, Devens, MA, Hema Madhuri Mekala, M.D., Resident, Griffin Memorial Hospital, Norman, OK & Steven Lippmann M.D.

Additionally, 69% of participants had a complete alleviation of suicidal ideation following weekly infusions. Other research in 2020 compared esketamine to placebo in patients hospitalized for major depression with active suicidal intent. They received standard care or alternatively were treated twice weekly with esketamine 84mg nasal spray or a placebo nasal spray. A greater improvement in the depression scores was observed in those randomized to esketamine.

Interventions to prevent suicide are limited. Ketamine is an anaesthetic with dissociative properties that is also prescribed for treatment-resistant depression – a lack of clinical response to at least two oral antidepressant medication trials. Sub-anaesthetic doses of intravenous ketamine are observed to reduce suicidal ideation, sometimes within one hour. Thus, it should be well-suited for emergency interventions.

Ketamine should prove to be useful in helping patients who are acutely suicidal. This is particularly important at a time when the suicide rate is rising. How to Handel Sexual Feelings in Clinical Practice By: Gary Weinstein, MD

Its mechanism of action for treating depression remains unknown. Its affinity to the N-methyl-D-aspartate (NMDA), opioid, and α-amino-3-hydroxy-5-methyl-4isoxazolepropionic acid receptors might be explanatory. However, whether the NMDA receptor antagonist effect of ketamine is why it is effective is not clear. Memantine, another NMDA receptor antagonist, fails to work at all for affective disorders.

From Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry: A physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights: A psychiatrist shall not gratify his or her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his or her conduct has upon the boundaries of the doctor-patient relationship, and thus upon the well-being of the patient. These requirements become particularly important because of the essentially private, highly personal and sometimes intensely emotional nature of the relationship established with the psychiatrist.

Ketamine has two enantiomers – S-ketamine (esketamine) and R-ketamine (arketamine). Coadministration of ketamine with an oral antidepressant drug is utilized to treat unipolar depression. Both ketamine and esketamine utility were approved for unipolar depression in 2019, yet clinicians were advised to initiate them with caution and only after exhausting other pharmacological alternatives due to safety concerns. Ketamine can induce adverse events like dissociative, sedative, and mind-altering effects. In 2020, esketamine also received approval for short-term utility for countering suicidal ideation, when co-prescribed with an oral antidepressant.

A physician shall uphold the standards of professionalism, be honest in all professional interactions and strive to report physicians deficient in character or competence, or engaging in fraud or deception to appropriate entities: The requirement that the physician conduct himself/herself with propriety in his or her profession and in all the actions of his or her life is especially important in the case of the psychiatrist because the patient tends to model his or her behavior after that of his or her psychiatrist by identification. Further, the necessary intensity of the treatment relationship may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control. Additionally, the inherent inequality in the doctor-patient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical.

We looked at whether sub-anaesthetic doses of intravenous ketamine were more effective than a midazolam infusion to relieve suicidal ideation. We measured the Scale for Suicidal Ideation score at 24 hours post-infusion – suicidal thoughts in contrast to some suicide risk trials, which had only assessed suicide attempts. Adjunctive ketamine treatment yielded a significantly greater reduction in suicidal ideation. In 2020, it was hypothesized that repeated administration of intravenous ketamine diminished suicidal ideation longer than a single administration did. Changes in suicidal ideation were measured with the MontgomeryAsberg Depression Rating Scale and the Quick Inventory of Depressive Symptomatology-Self Report reporting scales. The data also supported that single infusions of ketamine were better at reducing suicidality, compared to midazolam. The effect peaked after seven days.

These principles are nothing new. This is part of the Hippocratic Oath from around 2600 years ago: “Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or

corruption, including the seduction of women or men, whether they are free men or slaves.”

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Questions about sexual attraction to clients were posed in a national survey of clinical psychologists Results: • Of the 585 psychologists who responded, 87% (95% of the men and 76% of the women) reported having been sexually attracted to their clients, at least on one occasion. • 63% percent felt guilty, anxious, or confused about the attraction. • About half of the respondents received no guidance or training on this issue. • Only 9% of the respondents felt their training was adequate concerning attraction. • 93.5% of the respondents – have never “acted out” sexually with their clients, stating that such activity was “unethical,” “exploitative,” “unprofessional”, and “against the therapist’s values.” • Of the remaining 6.5% who had been intimate with their clients, male therapists outnumbered females four to one.

• • • • • •

Changing the office’s business practices (e.g., scheduling late appointments when no one is around, having sessions away from the office, etc.). Confiding in a patient (e.g., about the therapist’s love life, work problems, loneliness, marital problems). Telling a patient that they are special, or that the therapist loves them. Relying on a patient for personal and emotional support. Giving or receiving significant gifts. Suggesting or supporting the patient’s isolation from social support systems, increasing dependency on the therapist. Providing or using alcohol or drugs during sessions.

It also listed common patient reactions to therapist sexual misconduct: • Intimidated or threatened. • Guilt and responsibility. • Mixed feelings about the therapist, e.g., protectiveness, anger, love, betrayal. • Isolation and emptiness. • Fearful that no one will believe you. • Feeling victimized or violated. • Experiencing traumatic symptoms, e.g., anxiety, nightmares, obsessive thoughts, depression, or suicidal or homicidal thoughts.

In a survey of 1000 psychiatrists, over 30 years ago, 7.1% acknowledged sexual contact with a patient, 88% occurring between a male psychiatrist and female patient. It is not uncommon to feel attraction to certain patients, but professionalism and ethical standards provide guideposts about what to do. • Seduction – To enter into a different state or position (to induce someone to engage in sexual activity • Transference – Feelings, desires and expectations of one person (often a parent) are redirected and applied to the therapist • Countertransference – When the therapist unconsciously reacts to the transference in feelings toward the patient

The motivation for sexual misconduct with a patient most often comes from the therapist’s unconscious conflicts A – Long-standing and unresolved problems with selfesteem. B – Sexualization of pregenital needs. C – Restricted awareness of fantasy. D - Covert and sanctioned boundary transgressions by a parental figure. E – Unresolved anger toward authority figures. F – Intolerance of negative transference. G – Defensive transformation of countertransference hate into countertransference love.

Erotic Transference can occur for a number of reasons: • Love, whether in treatment or real life, often draws on earlier life experience. • It can be an attempt to exert control over therapy. • With insight and understanding, the therapist can help the patient understand conflictual feelings, particularly about past and present relationships.

Attraction to a Patient – What to Do: 1. Read your notes from the first session with the patient. Was there any clue that this might occur? 2. Reflect on where your feelings may be coming from. Understanding them can change your perspective and reduce the attraction. If it is countertransference, how can this be used to help the patient? 3. If the patient exhibits seductive behavior, what is the best way to discuss this? 4. If it is interfering with effective treatment, consider: • Discuss the situation with a colleague • Obtain supervision • Refer to a colleague for consultation 5. If you cannot handle your feelings adequately, refer the patient to a colleague. This does not denote fault or failure. It is just a way to get patients to someone who can help them.

The California Department of Consumer Affairs published warning signs to alert patients: • Telling sexual jokes or stories. • Sending obscene images or messages to the patient. • Unwanted physical contact. • Excessive out-of-session communication (e.g., text, phone, email, social media, etc.) not related to therapy. • Inviting a patient to lunch, dinner, or other social and professional activities. • Dating.

Protect Your Patient! Protect Yourself!

Dr. Harold Eist A Profile in Courage By: Shree Vinekar, MD

psychiatrists as our guest speakers since 1972, Harold was one of the best. I consider myself very fortunate to have had the opportunity of working with him. He made my participation in APA more enjoyable and meaningful. My wife and I will miss him sorely, as just about no other psychiatrist we have known showed as much enthusiasm for psychiatry and psychoanalysis as Harold did.

Harold Eist and I met because of his passion to defend the freedom of psychiatrists to help their patients. He was reading all the newsletters of the district branches and ran into my article titled “Where is mind in the mined field?” The article described how managed care was a “perfect business, deserving Nobel prize for its invention” because there was no other business in which the owner could entirely control the demand and supply, the cost of doing business, and also the profit. In this respect, the astronomical numbers describing the salaries of the CEOs of such managed care companies were the evidence that these companies were not motivated to provide economic health care – leave alone true quality of care. Harold contacted me and described his mission to oppose “managed care”; this was why he had run for the Presidency of the APA although he had not been nominated by the nominating committee. I enthusiastically supported him. He was elected, and he tried his best to change those whom he considered basically unethical. The belief that psychiatrists have the power to break the banks by providing honest care for honest fee-for-service had led to the fear that psychiatry would bankrupt the health industry. He could see through the irrational arguments. Besides, the participants seemed to have no respect for the conflict-of-interest principle. While maintaining collegiality, he could adroitly confront his colleagues. His struggle did not result in defeating managed care, but he made a dent in the general apathy.

IN MEMORIAM: HAROLD EIST, MD “Let Each Man Remember” By: Bruce Hershfield, MD I was on the dais of the APA Assembly in 2003 when Harold got its Profile of Courage award. I was more impressed by that than by any of his other accomplishments. Harry Truman, who knew something about these things, commented when he gave the Congressional Medal of Honor to 15 men, including the hero of Hacksaw Ridge – Desmond Doss – that he would much rather have that medal around his neck than to be President. “It is the greatest honor that can come to a man.” Harold spent a lifetime standing up for those who needed a friend. When he was the North American Rep to the World Psychiatric Association, he met with China’s Deputy Minister of Health to discuss how the Chinese were treating the Falun Gong. He stood up to the big businesses that were skimming money from patients under the heading of “managing” their care. He stood up to the Maryland Board of Medicine for years and at great cost to protect patients from losing their confidentiality.

He refused to accept payment from health insurance companies and relied on patients to pay his fees. Those who knew him appreciated his courage. I wanted to nominate him for the Catcher in the Rye award of the American Academy of Child and Adolescent Psychiatry, and I brought it up with him. He felt he had been honored sufficiently by his colleagues by giving him the APA’s Assembly Profile of Courage award for protecting the privacy and confidentiality of patients against the Medical Board. It cost him a fortune, but he did not give up. Finally, he was recognized by his medical school – the University of Edmonton – as a highly deserving alumnus.

The Washington Post said in his obituary that he was a warrior for the disenfranchised and was known as the “Winston Churchill of Psychiatry”. Churchill had a long history of standing up for the friendless and oppressed. And, of course, he was brave – like Harold. Michael Olesker said in the Baltimore “Sun” years ago that you can say what you want about the British, but you can’t take 1940 away from them. When he was 15, he kissed goodbye to his nursemaid, who had come to visit him at Harrow, in front of the other boys. One of his classmates commented many years later that it was still the bravest thing he had ever seen anyone do.

He took up for the patients and for his fellow psychiatrists. We developed a lasting friendship, and I invited him many times as our distinguished guest faculty at the district branch meetings, at grand rounds and for our convocations of Residents at the Oklahoma University Health Sciences Center. He described how he had learned to offer psychotherapy even to schizophrenic patients under the guidance of “another” Harold – Harold Searles. His clinical skills as an analyst, which he was able to demonstrate in case presentations, were superb.

I was impressed, the last few times I saw Harold, at meetings of the Maryland Psychiatric Society in the Baltimore area, by the effort he made to travel despite his health. I saw it with my own eyes – I don’t need to be told about Falun Gong and the Board of Medicine. Walter Mondale said when he eulogized Hubert Humphrey – who also was a friend to those who needed one – that he taught us how to live and he taught us how to die.

I must say that after having had the good fortune of entertaining nearly 200 renowned training analysts and

I have no medal to give as a token of my appreciation for what he did for me by setting these examples. I only have words. So let me quote from a 1940 poem by Josephine Jacobsen, who lived in Baltimore for 80 years. It’s called “Let Each Man Remember”. It speaks to how Harold’s life can inspire each of us to be brave.

Area V Council from the APA Assembly plans to meet conjointly with us in September in Baltimore. I think we can adapt, and we can thrive – if we are willing to change. We can talk with each other in-between the times we can touch each other again. And now we can also do that once again.

She talked about how many people have to get out of bed and do something they dread on a particular morning:

Buck wrote it just right and then he sang it: “No, nothing else matters now, We’re together again.”

“With nothing to gain, perhaps, and no sane reason To put up a fight, they grip and hang by the thread As fierce and still as a swinging threatened spider. They are too brave to say, ‘It is simpler to be dead.’ Let each man remember, who opens his eyes to that morning, How many men have braced him to meet that light And pious or ribald, one way or another, how many Will smile in its face, when he is at peace in the night.”

2022 Annual Meeting–Baltimore, MD With Maryland Psychiatric Society September 7 – 11, 2022 Royal Sonesta Hotel – Baltimore, Maryland

I believe the most important line in the Passover service is: “Let me recount what the Lord did for me when I came out of Egypt.” It is because of what Harold – and others – have shown us by their example that we can face any morning with courage, as they have.

LETTER from the EDITOR: Together Again By: Bruce Hershfield, MD

A not to miss event: Sac Au Lait performing live at The Farewell Gala on Saturday, September 10

I was pleased to attend the reception the Southern and PRMS hosted at the Chicory restaurant in New Orleans on May 22nd. When I saw Dave Casey, our president, and his wife Valerie, I told her it was like the song “Together Again”. Then I found it on Google and played part of it on my phone for her. It was Buck Owens and the Buckaroos – the “Bakersfield sound”. It’s been a strange time since we last met in person in Louisville in 2019. I think Janet Bryan and the officers who did their jobs for two years instead of one – plus the current ones – deserve a lot of credit. It required a lot of technological skill and a ton of patience to keep us moving forward without in-person meetings. But seeing people on a flat screen is not the same as shaking their hands and hugging them.

2023 Annual Meeting–Huntsville, AL With Alabama Psychiatric Physicians Association October 11 – 14, 2023 The Westin Huntsville, Huntsville, AL

Janet is getting the Zoom social meetings started this month, and I am hoping folks will participate. It should be a good way of communicating in-between the in-person meetings in the fall and the spring. It is important for us to talk with each other as much as possible in these troubled times. Instead of just one meeting a year, we have developed a newsletter, gotten a Rep to the APA Assembly, and partnered with PRMS so we can meet each spring. The SPA Council allotted $5,000 to update our website. The

SPA OFFICERS 2021-2022 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 “Southlands” articles represent the views of the authors and are not official positions of the Southern Psychiatric Association. Comments and Letters to the Editor are welcome and should be addressed to the Editor at BHershfiel@aol.com (Bruce Hershfield, MD, 1415 Cold Bottom Rd, Sparks, MD 21152)

“SOUTHLANDS” EDITORIAL ADVISORY BOARD William Greenberg, MD Steven Lippmann, MD Jessica Merkel-Keller, MD Denis J. Milke, MD Editor: Bruce Hershfield, MD Assistant Editor: Janet Bryan