University of Iowa – Page 12 – Go Retire Psychiatrist

Exercise for Brain Health

University of Iowa research shows that exercise could help for protecting us against Alzheimer’s disease. After age 65, our risk for this category of dementia doubles every 5 years.

Even if scientists develop effective and safe senolytic compounds that could allow us to live to be 200 years old, that won’t be happening in the near future. There’s another way to help prevent Alzheimer’s disease.

Exercise can lower the risk for Alzheimer’s disease, especially some form of aerobic exercise.

When it comes to exercise, any exercise is better than none.

Overdiagnosis of Psychiatric Disorders Still Happens

I read an excellent article in Clinical Psychiatry News recently in the Hard Talk section. The title is “A prescription for de-diagnosing” by psychiatrists Nicholas Badre, MD and David Lehman, MD in the July 2022 issue (Vol 50, No. 7).

The bottom line is that too many psychiatric patients have too many psychiatric diagnoses. A lot of patients have conflicting diagnoses (both unipolar and bipolar affective disorder for example) and take many psychotropic medications which may be unnecessary and lead to side effects.

It takes time to get to know patients in order to ensure you’re not dropping diagnoses too quickly. Discussing them thoroughly in clinic or in the hospital is an excellent idea. And after getting to know patients as people, it makes sense to discuss reduction in polypharmacy, which can be quite a burden.

This reminds me of the Single Question in Delirium (SQiD), a test to diagnose delirium by simply asking a friend or family member of a patient whether their loved one seems to be more confused lately. It’s a pretty accurate test as it turns out.

This also reminds me of the difficulty in making an accurate diagnosis of bipolar disorder. I and a Chief Resident wrote an article for The Carlat Report in 2012 (TCPR, July / August 2012, Vol 10, Issue 8, “Is Bipolar Disorder Over-Diagnosed?”) which warned against overdiagnosis of bipolar disorder. Excerpts below:

Some argue that bipolar disorder is actually under-diagnosed. They have support from abundant literature showing that bipolar disorder tends to present more often with depression than mania or hypomania (Judd LL et al, Arch Gen Psychiatry 2002:59(6):530–537). As many as 10% of patients with unipolar depression ultimately are shown to have bipolar illness instead, according to some experts (Goodwin GM et al, Eur Neuropsychopharm 2008:18(7):535–549). (See this month’s Q&A with Claudia Baldassano for more on this.) In addition, a new emphasis on subthreshold mood symptoms and more rapid mood shifts has led some psychiatrists to promote the concept of a “bipolar spectrum disorder” (Youngstrom EA et al, Curr Psychiatry Rep 2010;12(6):479–489).

While it’s important to remain vigilant about a history of manic and hypomanic symptoms, we think the problem of over-diagnosis is probably greater. For instance, in a 2008 study, Zimmerman and colleagues performed a comprehensive diagnostic interview on 700 patients, nearly 21% of who self-reported a history of “bipolar disorder.” However, when using the gold-standard SCID (structured clinical interview), only 13% had the diagnosis; they also had more first-degree relatives with bipolar disorder than the others (Zimmerman M, Ruggero CJ et al, J Clin Psychiatry 2008:69(6):935–940). The authors hypothesized that over-diagnosis of bipolar disorder might be a consequence of efforts to improve recognition of it and avoid under-detection. In fact, the same authors studied 40 depressed patients previously diagnosed with bipolar disorder and found that, by the SCID, they had specific phobia, PTSD, drug abuse/dependence, or a personality disorder instead (Zimmerman M et al, Compr Psychiatry 2010;51(2):99–105).

Over-diagnosis can also occur when apparent mood episodes are defined as psychiatric when in fact, they have a different etiology altogether. Decreased need for sleep, disorganized or racing thoughts, increased activity and agitation, and delusional thinking, even when they occur together, can represent a sort of “final common pathway” for medical conditions and other syndromes. The manic phenotype can occur in patients with agitated delirium, brain tumors, corticosteroid treatment, and of course substance intoxication (Bunevicius A et al, CNS Spectr 2008;13(11):950–958; Brooks JO and Hoblyn JC, Am J Psychiatry 2005;162(11):2033–2038). These other phenotypes can be distinguished by recognition of key features such as the fluctuating nature of consciousness in delirium, neuroimaging findings, and positive urine drug screens.

Unfortunately, physicians may also be susceptible to diagnostic shortcuts. When faced with limited time for diagnostic interviews and the pressure to prescribe by patients and their families, well-meaning clinicians may give the diagnosis after a single brief interview. Not uncommonly, we find that it was diagnosed on the basis of mood fluctuation over minutes, temper tantrums, and fleeting insomnia. The rapidly expanding repertoire of medications approved for bipolar disorder, and their relative ease of use, may also contribute to over-diagnosis. Unfortunately, in some cases the treatment may be worse than the symptoms themselves (Iordache I and Low NC, J Psychiatry Neurosci 2010;35(3): E3–4).

I was accustomed to asking what I called the Single Question in Bipolar (SQiB). I frequently saw patients who said their psychiatrists had diagnosed them with bipolar disorder. I would ask them, “Can you tell me about your manic episodes?”

Often, they looked puzzled and replied, “What’s a manic episode?” I would describe the typical symptoms and they would deny ever having them.

The article by Drs. Badre and Lehman is a bit disappointing in that it doesn’t look as though we’ve improved our diagnostic acumen much in the last decade.

We need to try harder.

Thoughts on the Song “Against the Wind”

A couple of days ago, while we were playing cribbage, Sena asked me who sang the song “Against the Wind.” I offered a name, which later turned out to be wildly wrong. It bugged her so much she got up from the cribbage game and went to the computer to look it up.

Of course, Bob Seger wrote the lyrics and sang it. She asked me what I thought it meant. I wasn’t sure at the time. I hadn’t thought about it for a really long time.

I read about it on the web. I didn’t know what the lyric “8 miles a minute” meant and found a forum message saying that it corresponds roughly to the speed of a cruising airliner which is about a “480 mph.” That’s technically more like 480 knots, which converts to about 550 mph.

Anyway, it’s really fast and might be a way of saying you’re moving through life at breakneck speed. In Seger’s case, it might have had a more concrete meaning, referring to flying all over from concert to concert.

The song was released in 1980, which was about the time we moved to Ames so I could go back to college at Iowa State University (ISU). It was a big change from working as a draftsman and land surveyor’s assistant in my hometown of Mason City.

If you extend the “against the wind” metaphor a little bit, Sena and I were both moving against the wind in terms of our place in society, income level, location and educational attainment. I thought I wanted to be an engineer at the time, mostly because I had worked for years for consulting engineers.

Backing up in time a little, I had done some undergraduate college work previously at an HBCU (historically black college/university), Huston-Tillotson College (now Huston-Tillotson University) in Austin, Texas in the mid-1970s.

That was also a kind of move against the wind. I grew up in Mason City, and often I was the only black kid in grade school. I got used to that, although the racism was more overt back then and it was difficult sometimes to bear up against that kind of wind. On the other hand, I felt like a fish out of water at H-TC. I just felt like I didn’t fit in. It was part of the reason I left Austin.

It was also challenging to fit in at ISU. I figured out quickly that I would never complete the engineering degree program. The math and hard science courses were tough from the beginning and only got harder. I realized I was going against the wind there.

So, I changed my major and settled on medical technology, which led to working in a hospital laboratory. But it took about a year to get a job after graduation. Looking back, It was a frustrating time and that really felt like pushing against a headwind. I don’t know what I would have done without Sena.

I finally got into medical school at the University of Iowa. Biostatistics and Biochemistry were brutal. I was very close to quitting before the 3^rd year of clinical rotations. I doubted I was cut out to be a physician. I thought about going back to surveying. But I didn’t.

Many deadlines, commitments, and struggles leading to brief forays from academia into private practice led me to think of myself as more of a fireman or a cowboy than an academician. Yet I spent most of my career at the University of Iowa.

Now I’m retired. Sena is my shelter against the wind. I guess if you look hard enough, just about anybody can relate to Bob Seger’s song. Let the cowboys ride.

Thoughts on the GuideLink Center Incident

The attack a few days ago by what was most likely a mentally ill person on staff at the recently opened GuideLink Center in Iowa City reminded me of what may appear to be disparate views by mental health professionals on the link between mental illness and mass violence perpetrators.

The GuideLink incident involved a person who assaulted GuideLink staff and who also left bags containing incendiary devices at the center and another building in Iowa City. The person is being charged with terrorism and is currently in custody in the Johnson County Jail.

I have not seen information about any injuries sustained by the mental health center staff. There were no explosions or fires at either location where incendiary devices were left. Bomb squad experts removed the devices. It’s not clear whether the perpetrator had been a GuideLink Center client.

The GuideLink Center opened in February 2021 and by all reports is a welcome and very much needed crisis stabilization mental health resource in the community. The staff members are dedicated to their calling.

Dr. H. Steven Moffic, MD, a retired psychiatrist who writes for Psychiatric Times, readily says that the perpetrators sometimes do have mental illness that at least contributes to committing acts of mass violence. Dr. George Dawson, MD, another retired psychiatrist, seems to say that the major reason for mass shootings is the ready availability of guns, a culture of gun extremism, and mental illness accounts for a small proportion of acts of mass violence.

But neither Dr. Moffic nor Dr. Dawson say that it’s only either mental illness or guns (or other instrument of mass violence) that lead to acts of mass violence. Both are important.

I’m a third retired psychiatrist and by now some readers might be asking themselves whether they should listen to any retired psychiatrist. Experience counts.

Speaking for myself, as a general hospital psychiatric consultant I was frequently faced with violent patients in the general hospital. Often, I found it necessary to ask a judge for a court order to involuntarily hospitalize a violent and/or suicidal patient on a locked psychiatric unit by transfer from an open medical or postsurgical unit.

In order to obtain an order in the state of Iowa, I had to be able to state to the judge that the patient in question had a treatable mental disorder and was an acute threat to himself and/others. In most situations, I had an open bed on a locked psychiatric unit available ahead of time.

Even if a Code Green was necessary, I usually had an inpatient resource to which I could move the patient. A Code Green is a show of force or takedown maneuver by a specially trained team to control a violent patient while minimizing injury to everyone involved.

I don’t know if that kind of approach is even possible in a community crisis stabilization setting like the GuideLink Center. I think it’s fortunate that it partners with many other community resources including the Johnson County Sheriff’s Office.

The outcome of the incident at the GuideLink Center was that the overall safety of the staff, the patient, and the community was preserved. More resources like this are needed everywhere. They deserve all the support we can give them.

Update on James Alan McPherson Park Memorial Plaque

Sena suggested we send a message to Iowa City Mayor Bruce Teague inquiring about the proposed memorial plaque to James Alan McPherson, Pulitzer Prize winning author and longtime Iowa Writers’ Workshop faculty member.

I can remember only one other time in my life that I wrote a letter to an elected official. I wrote President Barack Obama in 2013, basically complaining about the Maintenance of Certification (MOC) program for physicians. I’m not sure what I expected him to do about it. Like many doctors, I was frustrated about the regulatory requirements from certification boards. I thought they were unnecessary and burdensome.

I received a reply which was completely off topic and probably not written by the President. The letter from “President Obama” didn’t answer or even come close to addressing the concerns about what I thought was regulatory harassment. In fact, I never kept the reply and forgot about it.

But the email to Mayor Bruce Teague was different. We just asked about the timeline on the memorial plaque for the James Alan McPherson Park, which was renamed last year. The celebration and ribbon cutting reveal of the new sign was in early August 2021. The memorial plaque was still in the planning stage. We’ve driven by the park several times in the last year looking for it.

Mayor Teague’s reply came the day after we sent our message. It was definitely pertinent and to the point. McPherson’s daughter Rachel is still looking over the wording on the mock-up of the plaque, considering what to include. After her approval, it would take about 10-12 weeks to complete.

Now that’s a quick and specific answer from a political leader. Mayor Teague also sings.

The Kids to Decide on the Next Hawkeye Wave Song!

The new Hawkeye Wave song will be decided by the kids, and it won’t be just a single song. According to a story in Iowa Now:

For every home game the Iowa football team plays inside Kinnick Stadium, the UI Department of Athletics, in coordination with the UI Stead Family Children’s Hospital Kid Captain program, will ask that week’s Kid Captain to help select a new song to accompany the Hawkeye Wave.

It’s a great idea! Back in April, fans were asked to nominate a song to be played between the first and second quarters of the Iowa Hawkeye football games while the team members and fans wave to the kids watching from UI Stead Family Children’s Hospital.

It’s up to the Kid Captains!

Learning About Monkeypox

The University of Iowa podcast Rounding@Iowa, hosted by Dr. Gerard Clancy, MD talked with Infectious Diseases specialist Dr. Jeffery Meier, MD about the essential facts about Monkeypox for health care professionals, recorded on June 2, 2022.

This podcast would also be interesting to anyone interested in learning more about Monkeypox.

How Hot?

It’s 97 degrees and with the heat index it feels like 103 this afternoon. There is an Excessive Heat Warning today. I was going to replace the sun room door jambs weather stripping today—but decided against it. I’d have to turn off the air conditioning and leave the door open. I did that yesterday when replacing weather stripping elsewhere in the house.

It takes a while to cool back down.

I’m reminded of working as a survey crew assistant way back when, working on new asphalt airport runway construction sites. That gets pretty hot.

On a 90-degree day, the asphalt temperature can get up to 110 degrees. Now imagine you have to work next to the asphalt paving machine. The asphalt mix usually arrives at the job site at a temperature of 275 to 300 degrees Fahrenheit.

I don’t recall ever seeing anyone pass out from the heat on those job sites. But it was awfully hard to drag yourself up and down the runway.

Temperatures today are nowhere near what it is on an asphalt paving job—but if you don’t have to work out there, it’s a lot safer to stay indoors with the air conditioning on than to venture out for very long in 100-degree temperatures.

You can risk heat exhaustion or heat stroke on days like this. Read about the different kinds of heat stress at the University of Iowa web site.

And from the time I started writing this post to the time I stopped, the temperature got up to 105 degrees with the heat index.

Stay cool.

Thoughts About Guns

I think there a lot better places to read about viewpoints on mass shootings than my blog. I recommend you check out Dr. George Dawson’s post “Gun Extremism Not Mental Illness,” posted on May 31, 2022, then read the editorial in Scientific American, “The Science is Clear: Gun Control Saves Lives,” posted on May 26, 2022.

I’m going to chime in mainly to show a few graphics I found which I think send a clear and simple message. Before I get to that, I just want to mention a few anecdotes to show how little hands-on experience I have with guns.

My earliest memory of any contact with firearms is in early childhood. My dad and a friend came home from a hunting trip with some rabbits for dinner for the family, which included my younger brother and my mother. I don’t know who cleaned or cooked them. I’m pretty sure my mom would not have had anything to do with them. I got my first taste and didn’t like it and said so to my dad. He introduced me to the word “gamey.” I didn’t know meat could taste gamey. The other thing I got from that meal was a mouthful of buckshot. I silently vowed I would never eat anything like it again while I lived.

My next encounter with guns was a YMCA program for kids to learn how to shoot. I might have been in my early teens, maybe even younger. We were given BB guns and instructed to do some target shooting. The paper bullseye targets were set up several yards away. I took many shots and collected my target to show the instructor.

I thought I hit it once and pointed to the hole. The instructor looked at it critically for a few seconds and then told me kindly that the hole was where the pin was stuck to fix the target to the wall. I never touched another gun.

Fast forward to when I was a third-year medical student getting through my clinical rotations at the University of Iowa. In 1991, a physics graduate student named Gang Lu shot and killed 6 people on campus including himself, wounded another rendering her paralyzed from the neck down, all apparently because he was not chosen to get an award for his dissertation. I remember feeling shocked when I read about it in the newspaper.

Now let’s move to some graphics I found at a website maintained by The University of Sydney, GunPolicydotorg, International firearm injury prevention and policy https://www.gunpolicy.org/. It makes it easy to put together comparison statistical graphics on things like gun violence. I compared the United States to New Zealand, Australia, and Canada. Click the next few links in order to get the message. In my opinion, I think the last one is a consequence of the first few.

I guess now it’s up to Congress. God help us all.