February 2025 – Go Retire Psychiatrist

Noteworthy Black Psychiatrists on the Last Day of Black History Month

I wanted to give a shout-out to Dr. H. Steven Moffic, MD for his article highlighting the career of a notable black psychiatrist, Dr. Alvin F. Poussaint, MD, who sadly died on February 24, 2025. I’m mortified that I hadn’t heard of him before now.

It reminded me of the time I mentioned another black psychiatrist I had never heard of either, Dr. Chester Middlebrook Pierce, MD, in a post about the book “Our Hidden Conversations” about a year ago.

I wondered if Dr. Pierce and Dr. Poussaint ever met. I looked this up but couldn’t find a definite link.

Dr. Moffic’s essay, in which he mentions antisemitism. also reminded me of an essay also published in Psychiatric Times in 2020 by Dr. Robert M. Kaplan, MD. The title is “Alois Maria Ott: I was Hitler’s Psychologist.”

It gives even more texture to Dr. Poussaint’s views on whether or when extreme racism should or should not be classified as a mental illness. My own residency training experience was marked by being assigned to a patient said to have schizophrenia—who angrily shouted when he saw me, “I don’t want no nigger doctor!” My faculty supervisor didn’t think I should be reassigned to an alternate patient, a decision I’m still ambivalent about.

FDA Announces Clozapine REMS Program Eliminated

As of February 24, 2025, the FDA has eliminated the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program. See the FDA link for details. Below is the announcement.

“Latest Update

February 24, 2025 – Beginning today, FDA does not expect prescribers, pharmacies, and patients to participate in the risk evaluation and mitigation strategies (REMS) program for clozapine or to report results of absolute neutrophil count (ANC) blood tests before pharmacies dispense clozapine. FDA still recommends that prescribers monitor patients’ ANC according to the monitoring frequencies described in the prescribing information. Information about severe neutropenia will remain in the prescribing information for all clozapine medicines, including in the existing Boxed Warnings.

Although the risk of severe neutropenia with clozapine still exists, FDA has determined that the REMS program for clozapine is no longer necessary to ensure the benefits of the medicine outweigh that risk. Eliminating the REMS is expected to decrease the burden on the health care delivery system and improve access to clozapine. FDA has notified the manufacturers that the clozapine REMS must be eliminated. FDA has instructed the clozapine manufacturers to formally submit a modification to eliminate the Clozapine REMS and to update the prescribing information, including removing mandatory reporting of ANC blood tests to the REMS program.

In the coming months, FDA will work with the clozapine manufacturers to update the prescribing information and eliminate the Clozapine REMS.”–FDA

The Pizza in a Bowl Enigma

Sena got a couple of pizza bowls and it’s quite an experience. It might be one of the things extraterrestrials would not invent because they don’t have mouths big enough to eat anything but chick peas one at a time.

Don’t get me wrong. The pizza tastes great. Has anybody figured out how to eat them? The importance of crust for pizza doesn’t occur to you until you don’t have it.

First of all (and second of all too for that matter), what is the etiquette required? How about the utensils? We tried eating them with spoons but then opted for forks. Adding a knife seems like overkill—until you find out how forks work.

You pick up the whole gooey mess and it gets all over your face. Have plenty of napkins ready, maybe even a wash cloth or a hose. I even use a knife and fork to eat pizza with a crust, which I admit some would call fastidious.

This reminds me of Pizza in a Cup. If you remember the movie “The Jerk,” which starred Steve Martin and Bernadette Peters, there’s the scene of them eating Pizza in a Cup. I can hardly believe that movie was released way back in 1979.

You can see that some of the comments below the YouTube indicate that not everybody believes the crust makes the pizza. Some even openly admit they purposely make pizza in a cup. And you can find recipes on the web for it. When I was in college, we went out for pizza with friends, one of whom blotted her pizza slice with a paper towel. I’ll bet she would have run away from pizza bowls.

Pizza in a bowl is in the same category as pizza in a cup—Foods That Puzzle You.

Bluebirds Fly on the Terry Trueblood Trail

We got out today on the Terry Trueblood Trail because it was sunny and 60 degrees. It felt like early spring, although Punxsutawney Phil put the kibosh on that.

The ice was giving way on Sand Lake. The birds were waking up and hungry. And I can’t remember the last time we saw bluebirds at all, let alone the many we saw out in the open grassland today.

It was the kind of day you forget what’s in the news and just celebrate the coming of spring. Just watch the bluebirds fly.

Addiction Not the Same as Neuroadaptation

It’s common to read or hear people say they’re “addicted” to all sorts of things, like chocolate, but there’s a difference between addiction and adaptation. Adaptation can also be called “dependence” or the fancier “neuroadaptation.”

This can foster a discussion about whether you can be addicted to antidepressants, which by extension, could mean it’s difficult to discontinue them. Presumably, that would point to withdrawal symptoms being the obstacle to “getting off” them. Comparing them in terms of which one is more difficult to quit (as noted in the news lately) is fraught with difficulty.

Because I’m a retired psychiatrist, I searched the medical literature to refresh my knowledge about the issue. It turns out, according to a recent review, that it’s important to distinguish between dependence (neuroadaptation) and addiction.

The thing about addiction is that it’s about misusing or abusing substances in a compulsive way despite adverse consequences. Medical students used to remember it (for exams) as the 4 C’s: compulsion, craving, control (the loss of), and consequences (negative). I remember one doctor who added another c: conniving (to obtain substances).

On the other hand, dependence is marked by the adaptation of brain receptors to a substance and which doesn’t involve any of the c’s. This is the way to differentiate addiction from dependence, the latter being a consequence of taking antidepressants. One recent review article does a pretty good job of explaining this:

“Physical dependence to antidepressants may occur in some patients, caused by adaptation of the brain to long-term use of the medication. As pharmacologically defined, this physical dependence is a distinct phenomenon from addiction, and is manifested by a drug withdrawal syndrome.” — Horowitz MA, Framer A, Hengartner MP, Sørensen A, Taylor D. Estimating Risk of Antidepressant Withdrawal from a Review of Published Data. CNS Drugs. 2023 Feb;37(2):143-157. doi: 10.1007/s40263-022-00960-y. Epub 2022 Dec 14. PMID: 36513909; PMCID: PMC9911477.

The authors make the point that pretty much all antidepressants can cause dependence if you take them long enough. But with the possible exception of tranylcypromine (Parnate), they don’t lead to abuse or addiction. That was an interesting reminder. Parnate has a chemical structure similar to amphetamine and there are old case reports describing patients who usually have other substance use disorders abusing Parnate.

Anyway, antidepressants can lead to dependence which can be detected only if they stop using them. Withdrawal can be extremely uncomfortable and can last weeks to months, uncommonly for years.

Withdrawal syndromes vary among different substances. Alcohol and heroin can cause severe withdrawal that has to be managed in a hospital. That’s not to say it’s impossible to suffer antidepressant withdrawal serious enough to warrant hospitalization, but it would be rare. Partly that’s due to the difference in neuroreceptors.

Serotonergic receptors, for example, can be occupied by serotonergic antidepressants and lead to dependence mediated by neuroadaptation. If the antidepressant is abruptly stopped, there will be withdrawal, partly depending on the chemical half-life of the drug. Withdrawal can be marked by headache, dizziness, falls, electric shock sensations, and suicide attempts, for example.

Opioid and benzodiazepine withdrawal are mediated by opioid and Gamma Amino Butyric Acid (GABA) receptors respectively. Withdrawal symptoms can include but are not limited to tremor, sweating, seizures and delirium for benzodiazepine withdrawal, and muscle jerks, sweating, bone pain, nausea and vomiting, diarrhea, and muscle spasms for opioids such as heroin. Both may require medical detoxification in a hospital.

Who’s to say which withdrawal syndrome is worse? They’re both bad.

There’s not a lot of scientific literature out there on antidepressant withdrawal. The authors of the article cited above ended up with only 11 papers over a 20-odd year span after their search.

On average, antidepressants with shorter half-lives tend to be associated with withdrawal. Table 5 in the article cited above identifies the ones with lower to higher risk. Table 6 is a preliminary effort to categorize the level of risk to develop antidepressant withdrawal for an individual patient.

Are There Clear and Consistent Racial Differences in Immunity?

So, the short answer is “Probably not.” I did a little digging on this because I heard the recently confirmed HHS Secretary Robert F. Kennedy Jr (RFK Jr) cite studies which he says did indicate there are differences in humoral immunity between Caucasians and African Americans.

Now remember, I’m a retired general hospital psychiatric consultant and my immunology background consists of the standard immunology lecture in medical school. The class I remember most vividly was the one in which the lecturer stopped her lecture abruptly, sighed deeply and looked defeated, probably because she saw the look of confusion on our faces.

Now that you know my credentials, let me just review what I found in a far from exhaustive review of the scientific literature on the topic of whether or not African Americans have, as RFK Jr. remarked, a “better” immune system than Caucasians.

On my own, I found what RFK Jr referred to variously (depending what social media web source you use) as the “Poland” or “pollen” studies as the scientific source of information supporting his view. I suspect it’s this, in which the last author in the citation is GA Poland:

Haralambieva IH, Salk HM, Lambert ND, Ovsyannikova IG, Kennedy RB, Warner ND, Pankratz VS, Poland GA. Associations between race, sex and immune response variations to rubella vaccination in two independent cohorts. Vaccine. 2014 Apr 7;32(17):1946-53. doi: 10.1016/j.vaccine.2014.01.090. Epub 2014 Feb 13. PMID: 24530932; PMCID: PMC3980440.

It was later in the day that I finally also found the NPR news story, the author of which pointed out the same article.

I also found a couple of other articles which tend to contradict the findings of the Poland et al study. One of them was published in eClinicalMedicine in 2023:

Martin CA, Nazareth J, Jarkhi A, Pan D, Das M, Logan N, Scott S, Bryant L, Abeywickrama N, Adeoye O, Ahmed A, Asif A, Bandi S, George N, Gohar M, Gray LJ, Kaszuba R, Mangwani J, Martin M, Moorthy A, Renals V, Teece L, Vail D, Khunti K, Moss P, Tattersall A, Hallis B, Otter AD, Rowe C, Willett BJ, Haldar P, Cooper A, Pareek M. Ethnic differences in cellular and humoral immune responses to SARS-CoV-2 vaccination in UK healthcare workers: a cross-sectional analysis. EClinicalMedicine. 2023 Apr;58:101926. doi: 10.1016/j.eclinm.2023.101926. Epub 2023 Apr 4. PMID: 37034357; PMCID: PMC10071048.

The list of references include the Poland study (reference 27) cited above. The bottom line is the African American immune response to Covid is not “better” than that of white health care workers but the Asian immune response was stronger. I thought it was interesting that in the section “Evidence before this study,” the authors point out that in one previous study, African Americans had lower antibody responses to vaccination than Whites.

I looked at only one other study, published in Clinical Microbiology Review in 2019;

Zimmermann P, Curtis N2019.Factors That Influence the Immune Response to Vaccination. Clin Microbiol Rev 32:10.1128/cmr.00084-18.https://doi.org/10.1128/cmr.00084-18

OK, so I didn’t hunt through all 582 references, but I thought it was enough to note that the authors didn’t mention race as even being relevant anywhere in the body of the paper.

That said, I suspect the more important fact to focus on is racial disparity regarding African Americans even getting vaccines, especially the Covid vaccine. Vaccine hesitancy is common in this population and probably more important to address rather than whether or not there are significant racial differences in immunogenicity. The major challenge is providing accurate information about vaccines in general and Covid vaccines in particular.

The CDC Advisory Committee includes African American members who attend each meeting and emphasize the importance of including black people in vaccination campaigns. OK, so why was the meeting this month cancelled, postponed, or whatever?

Hey, I’m just an old psychiatrist, so don’t take my word for it about anything here. Ask an immunologist. If the immunologist gives you a blank look, you could try a Ouija Board.

Old School

We were reminiscing about our elementary school days following a discussion of news article about what some educators want to do with the school day schedule. Apparently, kids are pretty sleepy in class and teachers think it’s because they’re sleep deprived. Apparently, they’re not getting enough sleep at night and the proposal is that the school day schedule ought to be pushed ahead, the day starting at 9 AM instead of 8 AM.

Maybe the kids should be off their electronic devices a little earlier in the evening.

I guess there have been studies supporting this idea for years, but of course I hadn’t heard of it. Nobody seems to be in a hurry to change the system.

What we remembered were the consequences imposed by teachers and principals when we didn’t perform up to expectations in class, or misbehaved in class or on the playground.

Sena had a little trouble with remembering the vowels, a e i o u and sometimes y. She had so much trouble with it that she had to stay after school to write that out over and over on two big blackboards. It took quite a while. That was back in the days when blackboards were big and covered one entire wall of the classroom. There was always more chalk available if she ran out. Sometimes the penalty for her not paying attention was a few sharp raps on the top of her head with a No.2 pencil. Most often it was for talking out of turn or not paying attention.

I got caught a couple of times for throwing snowballs on the playground. I think it was at least a couple of times. The consequence for this infraction was to sit in the principal’s office drawing little circles resembling snowballs on a sheet of paper. They had to be small so that it took you a long time to fill up the paper. If you made them too big, the principal made you flip the sheet over and do it again. I think if you got writer’s cramp, you had to switch hands.

My brother and I had to walk to and from school. We had to get up early and sometimes the snow was up to our knees. It was about a half-mile walk to school. One winter day, I was walking home and found a dog frozen stiff as a statue next to the sidewalk.

I spent most of time after lunch looking at the clock, wishing the hands would move faster to 3 PM, when school let out. I would walk home and because I was a latchkey kid, I just let myself in the house.

I guess moving the time up so that kids can be more awake during the morning wouldn’t hurt anything. Maybe the curriculum will be simplified a little bit too. Things like geography could be easier. You could change the name of the Gulf of Mexico (or is it the Gulf of America now?) to something that makes more sense—like the Gulf of Water.

If you can’t learn that, maybe you need to have your head rapped with a No.2 pencil.

Send The Asteroid; We Deserve It

About that news article regarding an asteroid colliding with earth—I couldn’t read it…hits too close to home (rim shot!).

More seriously (but not much!), the background for this is that the asteroid 2024 YR4 has been identified by NASA and is tracking it now. News stories emphasize its large size of maybe up to a few hundred feet and the low chance of it hitting earth at all. NASA’s latest estimate today of the probability of it hitting us at 0.28%. It’s scheduled to buzz by or through us in 2032.

I’m still trying to learn the terminology about rocks in and from space:

Asteroid: a rock that orbits the sun

Comet: an icy ball of dirt that orbits the sun

Meteor: a descriptive term about the amount of a certain edible substance, as in— “What did the black hole say after it swallowed an asteroid? It was good but I wish it had been a little meteor.”

Meteorite: a space rock that enters the earth’s atmosphere, creates a streak of light in the sky and lands on the earth’s surface.

Trilobite: a funny looking creature that died out during the mass extinction caused by a meteorite landing on the earth’s surface.

Any questions? No? Then let’s move on.

This should remind everyone of the well-known X-Files episode, “Tunguska.” Like many of the episode names, it’s pretty inscrutable unless you have a little background. Tunguska is an area in Siberia that in 1908 took a big hit from a cosmic event, basically an explosion of many megatons which flattened a forest of millions of trees. The impact occurred far up in the sky and was probably caused by a meteorite which left no impact crater.

Anyway, Agent Mulder talks about the Tunguska event as part of speculation about where a rock (found early in the episode) came from that has this black oil in it which infects humans (making them homicidal maniacs) and is made by extraterrestrials. Earlier a scientist speculated that the rock might be a meteorite containing fossilized extraterrestrial bacteria—just before the black oil got him.

Neil deGrasse Tyson, the famous astrophysicist remarked in a news report about this rock that now might not be a great time to cut funding to science.

So that’s why we should be asking ourselves, “Why are they called hemorrhoids? Because Asteroids was already taken.”

Get Ready to Vaccinate Your Chickens!

I’ve heard about the recent contract a drug company (Zoetis) obtained to make chicken vaccine for the H5N1 bird flu virus which is hopping from birds to cows and even to humans. So far, I haven’t heard that the bird flu is transmitted between humans.

As far as eating eggs, I’ve read that the chance of getting bird flu is pretty slim—but experts tell you to cook your eggs to a temperature above 165 degrees. No soft egg yolks for me.

Anyway, Zoetis is making a vaccine for chickens. I got to wondering how you would vaccinate chickens. Obviously, you have to catch them first, wrestle them down to the barnyard floor and stick a needle into them somewhere under all the feathers.

There’s a Wikihow with instructions (including a video) for giving chickens vaccines. One of them says to inject the bird in the spot for which you have the easiest access and which is the “most comfortable for the chicken.”

How do you tell which is the most comfortable spot for the chicken to be impaled by a needle? Maybe it’s marked by a Walgreens sticker. You have to sterilize the spot, maybe with a splash of that moonshine you’re making on your property. Make sure you don’t drink any of it during the vaccination process. You want to make sure of your aim.

When and how do you wrap a rubber band around the beak? You know darn well the chicken is going to peck you. You can tell we don’t have chickens in the backyard.

And then there are all the stories on the internet about how chickens can run around for a short while even after their heads are cut off. If they’re that energetic without their heads attached, how much more frantic are they going to be if they see you chasing after them with a needle? And remember, you’re going to probably poke them in the neck. Chickens know that. They also know you’re wearing only thin rubber gloves.

And aren’t chicken farms or ranches or coops, whatever, just chock full of thousands of chickens? Vaccinating all of them is a dawn to dusk proposition so you better have your Wheaties in the morning.

Are the roosters also up for the vaccine? One way to get them ready is to let them crow until they pass out. Then you can poke them. You’re welcome.

Rounding@Iowa Podcast: “Challenges in Transitioning Seriously Ill Patients from Pediatric to Adult Systems of Care”

I listened to the Rounding@Iowa podcast of February 11, 2025, “Challenges in Transitioning Seriously Ill Patients from Pediatric to Adult Systems of Care.”

86: Cancer Rates in Iowa – Rounding@IOWA

Iowa's cancer rates are among the highest in the country, and they are rising. In this episode of Rounding@Iowa, Dr. Gerry Clancy and guest experts Dr. Mary Charlton and Dr. Mark Burkard discuss the data, risk factors, and prevention strategies clinicians can use to make a difference. CME Credit Available: https://uiowa.cloud-cme.com/course/courseoverview?P=0&EID=81274 Host: Gerard Clancy, MD Senior Associate Dean for External Affairs Professor of Psychiatry and Emergency Medicine University of Iowa Carver College of Medicine Guests: Mark E. Burkard, MD, PhD Professor of Internal Medicine-Hematology, Oncology, and Blood and Marrow Transplantation University of Iowa Carver College of Medicine Director, University of Iowa Health Care Holden Comprehensive Cancer Center Mary Charlton, PhD Professor of Epidemiology Director, Iowa Cancer Registry Iowa College of Public Health Financial Disclosures: Dr. Clancy, Dr. Burkard, Dr. Charlton, and Rounding@IOWA planning committee members have disclosed no relevant financial relationships. Nurse: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this activity for a maximum of 0.75 ANCC contact hour. Pharmacist and Pharmacy Tech: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this knowledge-based activity for a maximum of 0.75 ACPE contact hours. Credit will be uploaded to the NABP CPE Monitor within 60 days after the activity completion. Pharmacists must provide their NABP ID and DOB (MMDD) to receive credit. UAN: JA0000310-0000-25-090-H99 Physician: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Other Health Care Providers: A certificate of completion will be available after successful completion of the course. (It is the responsibility of licensees to determine if this continuing education activity meets the requirements of their professional licensure board.) References/Resources: Iowa Cancer Plan

This was a very interesting presentation about the challenges of helping persons with life-limiting conditions (for example, hemophilia, cystic fibrosis, sickle cell anemia and more) transition from pediatric to adult systems of care. Most of the discussion was about the difficulty in finding doctors who would be willing and able to assume care of patients who had survived to adulthood who had been previously seen in pediatrics throughout childhood.

I listened very carefully to the whole podcast, waiting to hear about what the role of mental health care professionals would be in this kind of transition. There was no mention of it, not even after one of the presenters described a patient who was starting to have hallucinations.

My role as a consulting psychiatrist in a general hospital was mainly to see those with chronic diseases who were being treated by colleagues during a bout of cystic fibrosis or sickle cell crisis. I remember they were young adults, struggling with emotional distress and disruptive behavior.

I was surprised at the lack of discussion about the role of mental health assessments, diagnoses, and treatment including psychotherapy during transitions from pediatric to adult health care. Not that I would have had much to offer other than questions about how mental health professionals could be helpful regarding transitions—but I think they would have not been out of place.

I took a quick look at the resources provided. One of them was a University of Iowa website, the Iowa Center for Disabilities and Development: Transition to Adulthood Clinic For Teens and Young Adult Ages 14-30. Even here, the role of a psychologist was to evaluate learning problems.

One of the discussants mentioned a program called Got Transition, which has a very comprehensive website. There was a section for Special Populations and a list of resources and research when I searched the site using the term “mental health.” It was hard to find a section specific to the population under discussion in the podcast. On the other hand, it was very comprehensive.

In this podcast, discussants talked about the importance of a team approach to transitions. I wonder if there’s a place on the team for psychiatry.