On August 22, 2024, the FDA authorized new Covid-19 vaccines (2024-2025) “to include a monovalent (single) component that corresponds to the Omicron variant KP.2 strain of SARS-CoV-2. The mRNA COVID-19 vaccines have been updated with this formula to more closely target currently circulating variants and provide better protection against serious consequences of COVID-19, including hospitalization and death. Today’s actions relate to updated mRNA COVID-19 vaccines manufactured by ModernaTX Inc. and Pfizer Inc.”
Category: health care
Thoughts on the Homeless Mentally Ill
The homeless man who lives on the sidewalk outside our hotel reminds me of a couple of things. One is Dr. Gerard Clancy, MD who is University of Iowa Health Care Professor of Psychiatry, Professor of Emergency Medicine, and Senior Associate Dean of External Affairs.
I remember Gerry, who was in the department of psychiatry when I was a resident. I saw his picture in the newspaper and hearing about him riding a bicycle around Iowa City doing a sort of outreach to the homeless mentally ill.
I found an archived article mentioning him published in 1995 in the Daily Iowan. The story starts on the bottom of the front page, entitled “I.C. opens new doors for area’s mentally ill.” It continues on page 9A.
The story mentions Dr. Clancy and what was called then the Clinical Outreach Services and the Emergency Housing Program (EHP). The challenges then sound a lot like what they are now: long waiting lists for psychiatric evaluation and treatment, a lack of funding for the treatment of mental illness, and a lack of preventive care. The most common mental illnesses in the homeless mentally ill are chronic schizophrenia, schizoaffective disorder, and bipolar disorder. The idea of reaching out to them “on their own turf” as Clancy was quoted, was to help them feel more comfortable talking about their mental illness.
The housing situation for this population of those struggling with mental illness was dismal then and it’s still dismal.
The homeless guy I’ve been calling Bob lives on the sidewalk next to a busy street. It’s just my opinion that he’s mentally ill based on my observations of his behavior. I’ve never tried to talk to him. However, Bob gets visits from people who obviously have differing views about the way he lives.
Some of them do talk to him and, although I can’t hear their conversations, the actions tell me important things. Some bring him what I call “care packages,” often food, water, and other items. They may start by acting kind, although may get impatient with him. Others try to clean up his sidewalk, and may criticize him. The police occasionally visit and have so far not taken him into custody.
It looks like things have not changed much since 1995 regarding the homeless mentally ill based on what I write here about my observations. In fact, it’s easy to find current news stories that say things are getting worse.
At the beginning of this post, I said I found a couple of things. The other thing was a very thorough teaching presentation about the current state of formal outreach to this population. It’s available on the web as a power point presentation by another University of Iowa faculty, Dr. Victoria Tann, MD, entitled “Assertive Community Treatment 101.”
Dr. Tann is currently an IMPACT Team psychiatrist. It’s an excellent source of background on the history of this effort at outreach to the homeless mentally ill. It also summarizes what’s happening with the program now.
Alcohol is Bad for Old Guys
I took a quick peek at the study published recently in the Journal of the American Medical Association (JAMA) that a few news agencies are reporting on which says alcohol in moderation is bad for older persons. So much for moderation.
Actually, the full abstract is:
Ortolá R, Sotos-Prieto M, García-Esquinas E, Galán I, Rodríguez-Artalejo F. Alcohol Consumption Patterns and Mortality Among Older Adults With Health-Related or Socioeconomic Risk Factors. JAMA Netw Open. 2024;7(8):e2424495. doi:10.1001/jamanetworkopen.2024.24495
“Conclusions and Relevance: In this cohort study of older drinkers from the UK, even low-risk drinking was associated with higher mortality among older adults with health-related or socioeconomic risk factors. The attenuation of mortality observed for wine preference and drinking only during meals requires further investigation, as it may mostly reflect the effect of healthier lifestyles, slower alcohol absorption, or nonalcoholic components of beverages.”
Conclusions: “This cohort study among older drinkers from the UK did not find evidence of a beneficial association between low-risk alcohol consumption and mortality; however, we observed a detrimental association of even low-risk drinking in individuals with socioeconomic or health-related risk factors, especially for cancer deaths. The attenuation of the excess mortality associated with alcohol among individuals who preferred to drink wine or drink only during meals requires further investigation to elucidate the factors that may explain it. Finally, these results have important public health implications because they identify inequalities in the detrimental health outcomes associated with alcohol that should be addressed to reduce the high burden of disease of alcohol use.”
The news stories play a little fast and loose with the headlines, which tend to gloss over the effect of health-related and socioeconomic risk factors. But, there’s no doubt in my mind that most people could do without alcohol.
Personally, I would have a couple of 12-ounce bottles of beers while watching football games or listening to the Big Mo Blues Show on KCCK Blues and Jazz Radio station on Friday nights. I hardly drank at all in terms of the grams per day metric.
But I’ve not imbibed since we got so busy selling our old house and camping out in a hotel while waiting for our new house to be built. Not surprisingly, I don’t miss it. When I was a young guy, I drank more and even smoked cigarettes. That was a long time ago.
In fact, when I look back on those days, I remember the factors that tended to limit my use of those substances. Take cigarettes—to the landfill if you don’t mind. I was what you would call a “sometimey smoker” because after a few days I suffered a sore throat, blunted taste for food, stuffy nose, lower appetite (bad for a baseline skinny guy) and fatigue. I just couldn’t stick with smoking long enough to make it a habit.
I’m going to pick on wine a little because the article alludes to the idea that it might have some health benefit. When I was a kid, I once had a lot too much wine which led to a longstanding inability to even stand the smell of it for years. I still never drink wine.
There are many things that can be habit forming. I’m beginning to wonder if watching Men in Black movies might be one of my weaknesses. I don’t watch any other movies as often as I do the MIB trilogy films. I’ve watched them dozens of times and I don’t have a good explanation for it. I think they’re funny and I can always use a good laugh.
Agent K: After neuralyzing Officer James Edwards, he and Agent K are finishing a meal in a café while K is delivering the punchline to a joke, “Honey, this one’s eating my popcorn! Get it?” Agent K laughs uproariously.
Officer James Edwards: Looking dazed from the recent neuralyzer blast, asks “Who are you?”
Agent K: “You see, James, you are a nice young man, but you—need to lay off the sauce.”
The quote is probably not word for word. I didn’t look it up on the web. It’s just as I remember from seeing the movie so often. And that’s partly because, for the most part, I lay off the sauce.
Excelsior!
The health benefits of climbing stairs are well known and I’ve talked about them before. However, you haven’t really seen stair climbing in action until you’ve watched Sena ascend the stairs in our hotel.
There are 4 flights of 10 steps each. Doing it just once can puff you out. The keyword for this is “excelsior” which is Latin for “ever upward.”
Have a little sympathy for the cameraman who had to walk backward up the stairs, which is no small feat.
What About Bob?
The homeless guy camped next to the busy street just outside of our hotel is still here. I’m going to call him Bob because it’s awkward to keep calling him “the homeless guy.” I haven’t met Bob yet, but Sena got him some water. She had to give it to the hotel resident who so far is the only one who has been able to communicate with him.
Sena and I talked about what might be done for Bob. She noticed that his face was sunburned bad enough to cause the skin to peel off. Could a case be made for his being a danger to himself?
Of course, you could guess this issue would come up because I’m a retired psychiatrist. As an aside, I found an article published in the Daily Iowan early this year. The author interviewed several residents of a homeless camp who were displaced after a fire and subsequently the owners of the land closed the camp.
The homeless people at the camp were articulate and open to interview. Some of them were clearly choosing to be homeless and able to state how and why they did.
Bob might not be articulate enough to do that. He spends most of his time lying on the pavement with his blanket over him. It’s sometimes hard to tell if he’s out there until he moves. When he’s up, he usually stands up and waves his arms back and forth or sits on the grass. Occasionally, he moves in ways suggesting he’s acting out some kind of conversation with an invisible person.
A police officer stopped by, spoke briefly with Bob, and left. A woman stopped by and tried to help him clean up his room, so to speak. She picked up some of his trash and put it in a bag. She tried to get him to help, but he didn’t seem to understand.
What about Bob? Is he a danger to himself or others? Is he incapable of taking care of his basic self-care needs? Sooner or later, this would come up because the mental health laws would come into play. There are many homeless people out there living under bridges and camps. We’ve seen them when we go out for walks. Not all of them are definable as mentally ill.
There is guidance on the web about how to pursue a court-ordered psychiatric evaluation. I’m a retired psychiatrist and often was involved in those circumstances.
One way it works is that two people who are acquainted with the person go to the courthouse and complete paperwork to have someone ordered by a judge to be taken to the hospital for a mental health evaluation. If the judge signs an order, then typically the police would pick the person up and take them to the local emergency room. There aren’t vans with mental health professionals roaming the city looking for potential patients.
A psychiatrist performs a comprehensive mental health evaluation and later presents the report and testifies at a scheduled hearing. Attorneys are involved and give testimony for and against civil commitment. The patient also can speak. If the patient is court-ordered to inpatient treatment, that treatment is provided in the hospital usually. Periodic reports must be submitted to the court. Some people who are the objects of these interventions get better. Others don’t.
What’s missing here? You must at least know his real name to file for legal hold order. Although Sena says she saw Bob take out a cell phone, it’s not clear he knows how to use it or whether it even works. The only people who interact with him are those who are driving by and who show sympathy by buying food and water and other items for him. He usually tosses the empty water bottles in the parking lot where he sleeps. The police evidently didn’t think he needed an intervention from their perspective.
We don’t even know his real name. I haven’t tried to talk to him. I’ve never seen him act in a threatening way to anyone. Bob takes up one parking space and keeps his belongings within it. He usually lies under a blanket, often for several hours at a time. Bob doesn’t panhandle and I doubt he’s capable of that.
Am I Bob’s keeper?
Thoughts About Psychedelic Assisted Psychotherapy
I read the Psychiatric Times article “FDA Issues CRL to Lykos for MDMA-Assisted Therapy.” The short story is that the FDA essentially told the drug company Lykos that their study of the efficacy of MDMA-assisted treatment of PTSD needs more work.
I tried to wade through the on-line documents of the FDA’s meeting on June 4, 2024. There are hundreds of pages and I didn’t go through every page of the transcript. The minutes were succinct and much easier to digest.
I’m going to simply admit that I’m biased against using psychedelics in psychiatry for personal and professional reasons. I’m not a research scientist. I’m a retired consultation-liaison psychiatrist. I saw many patients with a variety of psychiatric diagnoses including PTSD and substance use disorders. I’m not opposed to clinical research in this area, but I’m aware of the difficulty of conducting it.
In that regard, I want to also admit that I’m very susceptible to being influenced by a former colleague’s remarks about the quality of the research in question in the Lykos study. Dr. Jess G. Fiedorowicz, MD, PhD formerly was formerly on staff at University of Iowa Health Care. He’s now the Chief of Mental Health at The Ottawa Hospital where he’s also Professor and Senior Research Chair in Adult Psychiatry, Department of Psychiatry, University of Ottawa, Ontario. His remarks in the transcript are typical for his erudition and expertise as a clinician scientist.
It’s difficult to wade through the pages of the FDA transcript and I couldn’t digest all of it, by any means. But if you’re interested in reading both sides of this issue, it’s a good place to get the best idea of the committee members’ thinking about it. The minutes are much easier to read and provide a succinct summary.
I realize the Psychiatric Times article editor doesn’t agree with the FDA recommendations for further study of psychedelic-assisted psychotherapy for PTSD. It may or may not influence the University of Iowa’s study of psilocybin. In my opinion, the FDA did the right thing.
Thoughts on Hobos and Homelessness
We can see the man from our hotel window. We assume he’s homeless. He has a small area where he sits on the curb next to the street. He does this most of the day. He has a blanket and a few other loose items which sometimes are strewn on the sidewalk or the grass.
Even in 90-plus heat, he’s out there, sometimes standing beneath a small tree, presumably for shade although it’s inadequate. He waves his arms around in what looks like a futile attempt to cool himself. He might just be restless. Other times he sits on his blanket. Occasionally, people stop their cars and seem to be trying to communicate with him. He most often ignores them.
One of the hotel residents approaches him sometimes. It looked like he gives him something (probably a cigarette). Once, the homeless man left his station by the street and walked over to the front of the hotel, waving his arms, seemingly because the hotel resident was speaking to him. We couldn’t see what happened after that, but when he returned to the street, he lit a cigarette. We also saw he accepted fluid, maybe a can of soda.
Later, some people in a car gave him something they bought in a nearby drive-up fast-food joint. He threw out the ice from his drink, which he didn’t consume and sprinkled the fluid on his arms. The people left and returned later with several items they gave him. Some of it looked like more water, which he again poured on his arms. There was a backpack or something like it. He didn’t seem to know what to do with it.
He couldn’t ignore them when they try to help him (water, food, etc.). One person tried to help him clean up his little camp by picking up his trash. The police came out to check on him. We couldn’t hear the short conversation. After she left, he continued to toss his water bottles and other items into the parking lot. He sleeps on the pavement.
This reminded me of a couple of times when I’ve seen hobos. I don’t see the homeless man as a hobo. The term “hobo” is not synonymous with homeless, vagrant, or tramp. Hobos prefer not to have a home, travel around to find work, may still ride the rails to get around, and don’t see themselves as tramps.
As a young man, I worked for consulting engineers as a draftsman and survey crew worker in Mason City. This was in the 1970s. We traveled to outlying cities. One day, we went to Britt for a job. It was during the Britt Hobo Days Convention. It was not the first time I ever heard of it.
Funny thing, I thought I recognized one of the hobos in the café where we got coffee. He was wolfing down a big breakfast. When he was finished, he left in a hurry. I just assumed he was a hobo in town for the festivities. But he looked so familiar.
And suddenly it dawned on me. He had been a kindergarten classmate of mine. I couldn’t recall his name, but it was him.
Another memory that occurred to me was much later in my life, when I was a psychiatrist and co-attending on the medical-psychiatry unit in University Hospital in Iowa City. We admitted a patient who had been found walking around and around in a circle in the street, and seemed confused. Evidently the patient had an acute medical problem and no diagnosable psychiatric illness.
The patient identified as a hobo and was proud of it. The person was polite, grateful, and cooperative. The person refused any help from us beyond help for the acute medical problem. We discharged the person to the street.
Hobo life is different nowadays, I gather. Many have cars and phones. If you look carefully at their photos on the Britt Hobo Days web site, they don’t make me think of homelessness or mental illness. They have made a choice.
On the other hand, homelessness is often not a choice and severe mental illness is not uncommon. There is a homeless shelter in Iowa City, and the resources include a supportive community living program for those who struggle with mental illness. One member of the board of directors is a psychiatrist. Not every homeless person wants to go there. The University of Iowa Health Care has an Integrated Multidisciplinary Program of Assertive Community Treatment (IMPACT).
Thoughts as Train Cars Visualization in Mindfulness Meditation
The Iowa Interstate Railroad train rumbles past our hotel a few times a day and it reminds me of the Mindfulness Based Stress Reduction (MBSR) course I took 10 years ago. One of the exercises the instructor mentioned was the train visualization mindfulness exercise. I don’t know if I remember what our instructor actually said about it, probably something like what the instructor says in a mindfulness video.
One thing I do remember is that it’s OK to notice my thoughts as train cars running through my head. The other thing is the train cars can sort of hijack me and off I go on a tangent, like a hobo hopping a freight car. And, what if also I notice the spaces between the train cars? What would that be like?
The side of my nose itches.
My left eye is tearing up.
What can I do about anything?
Are we all alone in the universe?
Why is David Attenborough’s voice so calming?
Why do I joke around so much?
Even after 10 years of mindfulness practice, I still notice my thoughts jumping around. I’m still hopping from box car to box car.
Verbal De-escalation: University of Colorado School of Medicine Video Series cont. Chapter 5
Simpson, Scott & Sakai, Joseph & Rylander, Melanie. (2019). A Free Online Video Series Teaching Verbal De-escalation for Agitated Patients. Academic Psychiatry. 44. 10.1007/s40596-019-01155-2.
Verbal De-escalation: University of Colorado School of Medicine Video Series cont. Chapter 4
Simpson, Scott & Sakai, Joseph & Rylander, Melanie. (2019). A Free Online Video Series Teaching Verbal De-escalation for Agitated Patients. Academic Psychiatry. 44. 10.1007/s40596-019-01155-2.
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