University of Iowa Psychiatry Residents Get Shout Outs

Recently, University of Iowa psychiatry residents worked hard enough to get shout outs. One of them was exemplary performance on the consultation and emergency room service. The service was following over two dozen inpatients and received 15 consultation requests in a day. This is a staggering number and the resident on the service did the job without complaints. In addition, the resident was the only trainee on the service at the time. Other residents were working very hard as well.

This high level of performance is outstanding and raises questions about health care system level approaches to supporting it.

I read the abstract of a recently published study about Mindfulness Based Stress Reduction (MBSR) compared to medication in treating anxiety in adults (Hoge EA, Bui E, Mete M, Dutton MA, Baker AW, Simon NM. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry. Published online November 09, 2022. doi:10.1001/jamapsychiatry.2022.3679).

On the day I read the abstract, I saw comments which were cringeworthy. The commenter is an outpatient psychiatrist in private practice who had some criticisms of the study. He thought the report of results at 8 weeks was inadequate because symptoms can recur soon after resolution.

Another problem he mentioned is worth quoting, “A course of treatment that requires as much time as the MBSR course described in the study would be out of the question for most of my patients, most of whom are overworked health care professionals who don’t have enough time to eat or sleep. Telling people who are that overworked they should spend 45 minutes a day meditating is the “Let them eat cake” of psychotherapy.”

That reminded me of a quote:

“You should sit in meditation for twenty minutes every day—unless you’re too busy; then you should sit for an hour.”

Zen Proverb

I know, I know; I should talk—I’m retired. Actually, I took part in an MBSR course about 8 years ago when I noticed that burnout was probably influencing my job performance on the psychiatry consultation service. I thought it was helpful and I still practice it. I was lucky enough to participate in the course after work hours. The hospital supported the course.

The residents who are being recognized for their hard work on extremely busy clinical services may or may not be at high risk for burnout. They are no doubt extra resilient and dedicated.

And the University of Iowa health care system may also be offering a high level of system support for them. I don’t see that University of Iowa Health Care is on the list of the American Medical Association (AMA) Joy in MedicineTM Health System Recognition System, but that doesn’t mean they aren’t doing the kinds of things which would merit formal recognition.

Anyway, they all get my shout out.

Intranasal Esketamine for Major Depression Available at University of Hospitals & Clinics Department of Psychiatry

Learn about the use of intranasal Esketamine for Major Depressive Disorder at the University of Iowa Hospitals and Clinics here.

Here We Go Again About Antidepressants

Back in August, my colleagues, Drs. George Dawson, MD and Ronald Pies, MD wrote a rejoinder in Psychiatric Times to a review article published in Molecular Psychiatry by J. Moncrieff, Mark Horowitz and others (Moncrieff J, Cooper RE, Stockmann T, Amendola S, Hengartner MP, Horowitz MA. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry. 2022 Jul 20. doi: 10.1038/s41380-022-01661-0. Epub ahead of print. PMID: 35854107.)

The idea that most psychiatrists subscribe to the so-called “chemical imbalance” theory of depression has arisen again in an article by Mark Horowitz on October 7, 2022. Sena alerted me to the article which is getting a lot of attention. There were well over 600 comments and counting about it when we read it on October 7th.

I would like to refer readers to the Dawson and Pies article, “The Serotonin Fixation: Much Ado About Nothing New,” published August 3, 2022. Since the issue about emotional blunting from SSRIs resurfaced again on October 7th, it wouldn’t hurt to review their September 26, 2022, Psychiatric Times article, “Antidepressants Do Not Work by Numbing Emotions.”

Psychiatrists Cast Doubt on Idea that Antidepressants Work by Causing Apathy

Out of 60 hits on page one of a Google search using terms “emotional blunting from SSRI,” only one cast doubt on the assumption that SSRI antidepressants exert their treatment effect by causing apathy. The rest endorsed the connection.

The one article I found on this quick search which contradicted this widely held and arguably incorrect assumption is “Antidepressants Do Not Work by Numbing Emotions,” published in Psychiatric Times, Sept. 26, 2022, which was written by George Dawson, MD and Ronald W. Pies, MD.

The authors wrote a convincing rebuttal of the assumption that the SSRI mechanism of action for treating depression is by causing apathy. Based on their review, the problem is more likely due to residual depressive symptoms. It’s a good thing it turns up on the first page of a web search.

Maybe We Need a Dose of Humor

Sena and I were listening to the Mike Waters morning radio show (KOKZ 105.7) this morning and his invitation to listeners was to call in and quote their favorite dumb question. One of the callers recited something which was actually a George Carlin joke. Neither one of us thought we heard it right, but it’s the same framework as the joke I found on the web (only the numbers were changed):

“If you’ve got 24 odds and ends on the table and 23 of them fall off, what’ve you got? An odd or an end?”

This is an example of his wordplay humor.

Carlin’s humor was also marked by satire on American culture and politics, the latter of which has gotten pretty rough. You’ll also find references on the web to Carlin’s past history of substance use, which reportedly included psychedelics.

That reminds me of an opinion piece published in the September issue of Current Psychiatry, by the journal’s editor, Henry A. Nasrallah, MD (From neuroplasticity to psychoplasticity: Psilocybin may reverse personality disorders and political fanaticism. Current Psychiatry. 2022 September, 21(9): 4-6 | doi: 10.12788/cp.0283).

I was a little surprised at Dr. Nasrallah’s enthusiastic endorsement of psilocybin for treatment of personality disorders and political extremism. He acknowledges the lack of any studies on the issue. In the last paragraph of his essay is a sweeping endorsement:

In the current political zeitgeist, could psychedelics such as psilocybin reduce or even eliminate political extremism and visceral hatred on all sides? It would be remarkable research to carry out to heal a politically divided populace. The dogma of untreatable personality disorders or hopelessly entrenched political extremism is on the chopping block, and psychedelics offer hope to splinter those beliefs by concurrently remodeling brain tissue (neuroplasticity) and rectifying the mindset (psychoplasticity).

While I’m not so sure about how effective psilocybin would be for this, I’m all for trying something to reduce the “visceral hatred on all sides.”

Maybe humor could be part of the solution. It doesn’t have to be exactly like that of George Carlin. Both parody and satire have been used by many writers for this.

I like the distinction between parody and satire in one article I found on the web. One recent example of satire (or parody; the distinction is sometimes hard to make since the story was listed as “Iowa Parodies”) was in the news and it apparently fooled at least a few people. It was about the Iowa football coaching staff. The title was “Brian Ferentz Promoted to University President To Avoid Having to Fire Him (Satire): The move was deemed ‘a way easier conversation than having him fired’ by the athletic director. It was written by Creighton M, posted September 5, 2022.

I think the story was originally printed without the word “Satire” in the title. I can’t recall seeing the heading “Iowa Parodies” either. A later version of the story added the word “Satire.”

The story might have been about nepotism in the hiring of Brian Ferentz (he’s the son of head coach Kirk Ferentz) as offensive coach. On the other hand, under Iowa law, it was not illegal to hire Brian Ferentz, who in any case reports to athletic director Gary Barta, not Kirk Ferentz.

I suspect the joke had more to do with negative public attitudes about the performance of the Iowa football offense early in the season.

Is it funny? I guess it depends on your perspective. The Iowa football coaching staff probably didn’t chuckle over it. But it more or less fits the definition of satire. It uses humor to expose flaws in the way we behave. And it avoids direct and nasty confrontation, which usually triggers antagonism rather than collaboration. Will it change the Iowa football program? I doubt it. They’re actually doing pretty good so far.

But satire as a strategy to inform and maybe change the public opinion will endure. The Hitchhiker’s Guide to the Galaxy by Douglas Adams is one of my favorite books and it satirizes governments and the foolishness of people. I first learned about The Onion newspaper while we were in the process of relocating to Wisconsin (a short adventure). It satirizes the Associated Press news style.

One of the most uproarious examples of parody is a TV show which is no longer available on cable television but still offered on a streaming service (I think), Mountain Monsters. It’s a hilarious sendup of all the Bigfoot hunter shows.

The added benefit of parody and satire and other such forms of humor is that they are safer than psychedelics—unless your target was born without a funny bone.

Ever See Bigfoot Splooting?

I wonder if anyone ever got a picture of Bigfoot splooting? Why not? It’s a large furry animal which has no way of cooling off other than by panting or lying on its belly with its limbs splayed out, which is the definition of “splooting.”

I found a news item about splooting squirrels and quickly found other examples of animals who sploot including but not limited to bears, dogs, and rabbits.

The word “sploot” turns up on a web site called Language Log, devoted to people who study word etymology.

And words definitely do matter, according to the authors of an opinion piece recently published in the Annals of Clinical Psychiatry (Black DW, Balon R. Words matter. Ann Clin Psychiatry. 2022 Aug;34(3):145-147. doi: 10.12788/acp.0072. PMID: 35849767).

I agree with Drs. Black and Balon. I dislike the word “issue,” for the same reason the authors do. It’s too vague. I have the same problem with “address” which I see in many news items headlines. which doesn’t give me a clue about what kind of action is being taken to solve a problem—other than just paying attention to it.

The word “sploot” drives my spell checker crazy. It’s not in the Merriam-Webster Dictionary. Neither is it in the Scrabble Dictionary. But it’s in the Collins English Dictionary, listed as British English.

Why “sploot” is any better than “splayed” is beyond me. If you have a picture of a splooting Bigfoot, let me know.

Featured image credit: Pixydotorg.

Thoughts on Suicide Risk Assessment

I know the term “suicide risk assessment” sounds very clinical. That’s because I did it for many years as a consultation-liaison psychiatrist in the general hospital.

The human part of it was using the suicide safety plan, which I got from the Centre for Applied Research in Mental Health & Addiction (CARMHA). You can download it yourself and adapt it by writing in the National Suicide Prevention Lifeline: 988 Suicide and Crisis Lifeline. That’s because the phone numbers on the form are specific to Canada.

Most often I interviewed patients in the intensive care units, where they were admitted after a suicide attempt. The interviews were very short if they refused to talk to me or were still delirious—often the case.

If they were awake and able to converse, the interviews were often pretty long. One way to connect with the patient was working on the safety plan together. I was often able to tell whether they were sincere or not by the level of detail they gave me about support persons they could get in touch with or things they could do to help them cope with whatever was troubling them.

A lack of detail in the plan, or refusal to work on some parts of it were areas of concern. If there were comments about friends, pets, or pastimes that spontaneously led to laughter (yes, that happened occasionally!), I was more confident that the patient was able to look toward the future and make specific plans for staying alive.

There is healthy debate about how useful specific suicide risk assessment scales are for predicting and preventing suicide. They are an essential part of the computerized medical records now, whatever anyone thinks of their reliability at predicting imminent suicide. I never used no-suicide contracts because well before the time I entered professional practice, most experts agreed that they don’t prevent suicide.

What was more useful for me as a clinician was to sit down at the patient’s bedside and, after getting the details about what the patient actually did in the suicide attempt and the events connected with it (along with a comprehensive and thorough history), I would get the safety plan from my clipboard, hold it up so they could see it and say, “Now let’s work on this; it’s your safety plan.”

I can’t tell you how often working on those plans, frequently for more than half an hour, led to laughter as well as tears from the patient. When it worked, meaning the relationship between us deepened, I sometimes did not find it necessary to admit the person to the psychiatric ward. While this occasionally alarmed the ICU nurses, things usually turned out fine later.

A Retired Consultation-Liaison Psychiatrist’s Perspective on Eating Disorders

This is just my presentation on eating disorders vs disordered eating for a Gastrointestinal Disease Department grand rounds several years ago. What’s also helpful is an eating disorder section on the National Neuroscience Curriculum Initiative (NNCI) web site. I left comments and questions there, which the presenter answered.

In addition, the Academy of Consultation-Liaison Psychiatry (ACLP) has an excellent web site and here is the link to a couple of fascinating presentations from the ACLP 2017 annual meeting on management of severe eating disorders, including a report on successful treatment using collaboration between internal medicine and psychiatry.

If you can’t find it from the link, navigate to the Live Learning Center from the ACLP home page and type “eating disorder” in the search field. One of the presentations is entitled “Has She Reached the End of Her Illness Process.” The other is entitled “Creating Inter-Institutional Collaborative Care Models.”

This is a very complex area of medicine and psychiatry. There are no simple solutions, although many experts across the country are hard at work on finding practical solutions.

The caveat is that the information here is not updated for recent changes in the literature.

What Would Make Psychiatry More Fun?

I just read Dr. George Dawson’s post “Happy Labor Day” published August 31, 2022. As usual, he’s right on the mark about what makes it very difficult to enjoy psychiatric practice.

And then, I looked on the web for anything on Roger Kathol, MD, FACLP. There’s a YouTube video of my old teacher on the Academy of Consultation-Liaison Psychiatry (ACLP) YouTube site. I gave up my membership a few years ago in anticipation of my retirement.

I think one of my best memories about my psychiatric training was the rotation through the Medical-Psychiatry Unit (MPU). I remember at one time he wanted to call it the Complexity Intervention Unit (CIU)—which I resisted but which made perfect sense. Medical, behavioral, social, and other factors all played roles in the patient presentations we commonly encountered with out patients on that unit where we all worked so hard.

Dr. Kathol made work fun. In fact, he used to read selections from a book about Galen, the Greek physician, writer and philosopher while rounding on the MPU. One day, after I had been up all night on call on the unit, I realized I was supposed to give a short presentation on the evaluation of sodium abnormalities.

I think Roger let me off the hook when he saw me nodding off during a reading from the Galen tome.

Dr. Dawson is right about the need to bring back interest, fun and a sense of humor as well as a sense of being a part of what Roger calls the “House of Medicine.” He outlines what that means in the video.

What made medicine interesting to me and other trainees who had the privilege of working with Roger was his background of training in both internal medicine and psychiatry. He also had a great deal of energy, dedication, and knew how to have fun. He is a great teacher and the House of Medicine needs to remember how valuable an asset a great teacher is.

Psychiatric Polypharmacy: An Opportunity to Teach with CPCP

Dr. H. Steven Moffic discussed the issue with psychiatric polypharmacy in his August 29, 2022 entry on Psychiatric Views on the Daily News. The patient who had been getting 10 psychotropic drugs was found to have a medical problem ultimately, which led to simplification of the complex regimen.

This is a great opportunity to again mention the value of what was a regular part of the teaching component of the University of Iowa Hospital Consultation-Liaison Psychiatry service, at least until my retirement. This was the Clinical Problems in Consultation Psychiatry (CPCP) seminar. Once a week or so, when I was staffing the service, I and the trainees, which included medical students, and psychiatry residents as well as Pharmacy, Neurology, and/or Family Medicine residents.

Whenever we encountered a difficult and interesting case, which was almost every rotation, the trainees did a literature search to bone up on the clinical issue and gave a short presentation about it before consultation rounds. Often the case had both medical and psychiatric features.

I looked through my collection of student presentations and found one that might fit Dr. Moffic’s example in a general way. Medical problems can often look like psychiatric problems, which can include thyroid and other diseases. A very important one is autoimmune encephalitis, one example of which is anti-N-methyl-d-aspartate (NMDA) receptor encephalitis. There is an excellent summary of it in the August issue of Current Psychiatry entitled Is it psychosis, or an autoimmune encephalitis? (Current Psychiatry. 2022 August;21(8):31-38,44 | doi: 10.12788/cp.0273).

Several years ago, three medical students tag-teamed this topic and delivered a top-notch CPCP seminar summarizing the pertinent points. I hope the CPCP is still part of the educational curriculum.

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