featured – Go Retire Psychiatrist

Take a Cup of Kindness and Say Goodbye to 2021

It’s been a quiet day around here. It’s New Year’s Eve. I got a great message from a former resident who has started his own Psychiatry Consultation Fellowship training program in Bangkok, Thailand. Dr. Paul Thisayakorn and his wife are welcoming 2022 with their 2 lovely children and hoping 2022 will be a better year, as we are. The Covid pandemic has been hard around the world.

Paul also looks forward to establishing a C-L Psychiatry academic society in Thailand in the coming year. Paul did his psychiatry residency at University of Iowa and his C-L Psychiatry fellowship in Cleveland. Sena and I wish him and his family all the best in the new year.

Today was quiet, but tomorrow the big snowstorm will come. We’ll be digging out all day because the forecast is for 5-8 inches, high wind gusts, and ice. It’s Iowa, after all.

But for tonight we’ll take a cup of kindness and say goodbye to 2021.

And if you like MacLean’s version of Auld Lang Syne above, you might have a listen to another with the Scottish lyrics translated.

My Definitive Journey Revisited

A couple of days ago, I got my retirement gift from The University of Iowa. It’s a about a year and a half late because of the Covid-19 pandemic, but it’s welcome nonetheless. Normally there is an Annual Faculty Retirement Dinner, but it had to be cancelled. It’s a stunningly beautiful engraved crystal bowl with the University logo on it. It came with a wonderful letter of appreciation. It reminded me of my blog post in 2019, “My Definitive Journey.”

It’s a definitive symbol of the next part of my journey in life. For years I’d been a fireman of sorts, which is what a general hospital psychiatric consultant really is. The other symbols have been the fireman’s helmet and the little chair I carried around so that I could sit with my patients. I have changed a little.

I still have my work email access, which I’m ambivalent about, naturally. I check it every day, partly because of Fear of Missing Out (FOMO), but also to delete the junk mail. I still get a lot of it. I get a rare message from former trainees, one of whom said it “pained” her to learn I’m now Professor Emeritus.

I have not seriously considered returning to work. That doesn’t mean I have not been occasionally nostalgic for some aspects of my former life.

The poem, “El Viaje Definitivo” by Juan Ramon Jimenez evokes mixed feelings and thoughts now. I have gone away. But in looking back at the past, I now see now that the birds didn’t always sing. The tree was not always green.

I don’t miss my former home, the hospital, as keenly now, which is now a much harder place to work since the Covid-19 pandemic began.

And there is little that is definitive about my journey forward from where I now stand. I’m a little less afraid than I was over a year and a half ago. And the birds sing where I am now, sometimes more clearly than before.

El Viaje Definitivo (The Final Journey)

… and I will go away.

And the birds will stay, singing

And my garden will stay

With its green tree

And white water well.

And every afternoon the sky will be blue and peaceful

And the pealing of bells will be like this afternoon’s

Peal of the bell of the high campanile.

They will die, all those who loved me

And every year the town will be revived, again

And in my circle of green white-limed flowering garden

My spirit will dwell nostalgic from tree to well.

And I will go away

And I will be lonely without my home

And without my tree with its green foliage

Without my white water well

Without the blue peaceful sky

And the birds will stay

Singing

–Juan Ramon Jimenez

Merry Christmas to My Wife…and to You

Christmas will be here Saturday and there’s no snow. At least we won’t have to shovel. I want to say a big thank you to my wife, Sena. She has put up with me for 44 Christmases. That’s asking a lot.

Here’s hoping for a better New Year in 2022. Happy holidays!

Let’s Play Chicago Cribbage!

Sena and I just went through a marathon of tries over a couple of days to make a YouTube video of a demo of how to play Chicago Cribbage (a variation of cribbage) and finally made it. We think it might be the first YouTube video of how to play Chicago Cribbage. You have to know basic cribbage to follow the gameplay, although you can still appreciate our antics whether you know the standard game or not. You can learn basic cribbage from my post “Kitchen Table Cribbage,” and the rules for Chicago Cribbage are posted on the web.

You need to know basic cribbage to play the Chicago Cribbage variation

No doubt you’ll find mistakes, but they’re nothing compared to the bloopers we made earlier. We forgot basic cribbage skills! And it was the best time we had playing cribbage in a while.

One thing we noticed was that it was a lot easier to play standard cribbage after trying to keep track of all the nuances of Chicago Cribbage. It takes longer to play but you don’t notice the time pass. We actually skipped one video segment to get the length of show down to about 15 minutes.

As usual, Sena won. You got me, babe!

Great YouTube Q&A on Covid-19 Vaccine for Children Ages 5-11: It’s better than a stick in the nose!

There was a great live stream YouTube Q&A presentation today on the Covid-19 vaccine for kids ages 5-11 through the University of Iowa Stead Family Children’s Hospital this afternoon at 2:15 and it ran for about 30 minutes (scrub the play button forward to about a minute to start the recorded video). There were excellent questions and informative answers as well as helpful guidance for parents by Chief Medical Officer Dr. Theresa Brennan, MD and Pediatrician Dr. Rami Boutros, MD.

Parents have been eager to bring their kids in to the pediatric clinic to get the vaccine. Dr. Boutros shared a funny anecdote about his interaction with a child who had just got his shot yesterday. It’s about 34 minutes into the video. After the child received the shot, Dr. Boutros asked him, “How was it?” The child replied, “The vaccine is better than a stick in the nose!” Anybody who’s been tested for Covid-19 can relate to that.

How’s that for a meme? Get the vaccine; it’s better than a stick in the nose!

What You See is Not Always What You Get

A couple of days ago I thought of Gary Larson’s Far Side cartoon, the one with the toggle switch in a passenger airplane cabin seat with the message “Wings Stay On; Wings Fall Off.” I googled it just for fun and found that it spawned a lot of web articles obviously trying to reassure the flying public that airplane wings don’t just fall off.

What brought the “Wings Stay On; Wings Fall Off” cartoon to mind were a few events in the last two days. Day before yesterday, Sena took our lease car to one of the local dealership’s car wash. She does this all the time without incident but this time she noticed that the “soap” didn’t rinse off. She drove it home and still couldn’t get what appeared to be soap film off the car. She finally drove back to the dealership and discovered that the car wash attendant had accidentally pressed the hydraulic oil lubricant button instead of the detergent button. A number of other car wash customers also had been victims of the mishap and were complaining to dealership management.

So, what had looked like soap film actually turned out to be hydraulic lubricant meant for the car wash motors. It turns out that accidents like these can happen. Could the button for the lubricant have been situated so close to the detergent button that the attendant accidentally pressed the wrong one? By itself, that reminded me of the Larson cartoon. If the systems analysist for the car wash design was asleep at the desk on the day of manufacture, I guess all you can do is think before you act. And what you see is not always what you get.

The next day, Sena and I were at the dealership sitting in an agent’s office. We noticed a tipped over cup of coffee. I reached over to pick it up, mentioning that he must have had a little accident. Much to my surprise, both cup and mess came up as a spill prank, which I had never seen before, believe it or not. The joke capitalizes on our human tendency to sometimes act before we think.

Finally, a couple of on-line news items caught my eye this morning. They were both about white tail deer in Iowa, discovered by Iowa State University (ISU) researchers to have somehow picked up the Covid-19 virus. One story was much shorter than the other.

The longer story by the Des Moines Register had a lot more ISU research detail in it and didn’t stress certain facts that might reassure readers that there was low likelihood that humans might be vulnerable to catching the virus from deer.

The shorter story by the KCCI news network didn’t present as much of the ISU research details and basically said as long as you used gloves to dress the animal in the field and thoroughly cooked the meat, you were in no danger of infection. Both stories basically carried the same message that there was low likelihood of infection to humans. But there was a slight tendency to overemphasize the risk in one article and maybe a tendency to underemphasize it in the other. These might illustrate the “spin” phenomenon for which readers should just be on the alert.

By the way, the CDC web site carries a message saying the risk of catching Covid-19 from wild animals is generally low.

What you see is not always what you get, especially at first glance. And it pays to think before you act.

Two Way Street Between Medicine and Psychiatry in Covid-19

I just found out that, as of the middle of this month, a new category, mental health disorders, has been added to the CDC list of medical conditions associated with higher risk for severe Covid-19 disease and thus, qualifies those in the category for receiving the COVID-19 vaccines . It makes sense. Mood, anxiety, and other neuropsychiatric disorders are known to be connected to a variety of medical conditions, such as diabetes mellitus, thyroid disease, and heart disease. Substance use disorders was already on the list previously. There are medical literature references supporting this:

Fond G, Nemani K, Etchecopar-Etchart D, Loundou A, Goff DC, Lee SW, Lancon C, Auquier P, Baumstarck K, Llorca PM, Yon DK, Boyer L. Association Between Mental Health Disorders and Mortality Among Patients With COVID-19 in 7 Countries: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2021 Jul 27:e212274. doi: 10.1001/jamapsychiatry.2021.2274. Epub ahead of print. PMID: 34313711; PMCID: PMC8317055. https://pubmed.ncbi.nlm.nih.gov/34313711/

Ceban F, Nogo D, Carvalho IP, Lee Y, Nasri F, Xiong J, Lui LMW, Subramaniapillai M, Gill H, Liu RN, Joseph P, Teopiz KM, Cao B, Mansur RB, Lin K, Rosenblat JD, Ho RC, McIntyre RS. Association Between Mood Disorders and Risk of COVID-19 Infection, Hospitalization, and Death: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2021 Oct 1;78(10):1079-1091. doi: 10.1001/jamapsychiatry.2021.1818. PMID: 34319365; PMCID: PMC8319830. https://pubmed.ncbi.nlm.nih.gov/34319365/

It’s also interesting that a large randomized controlled trial of the antidepressant fluvoxamine showed that the agent reduced the need for hospitalization in high-risk outpatients diagnosed with early Covid-19:

Gilmar Reis, Eduardo Augusto dos Santos Moreira-Silva, Daniela Carla Medeiros Silva, Lehana Thabane, Aline Cruz Milagres, Thiago Santiago Ferreira, Castilho Vitor Quirino dos Santos, Vitoria Helena de Souza Campos, Ana Maria Ribeiro Nogueira, Ana Paula Figueiredo Guimaraes de Almeida, Eduardo Diniz Callegari, Adhemar Dias de Figueiredo Neto, Leonardo Cançado Monteiro Savassi, Maria Izabel Campos Simplicio, Luciene Barra Ribeiro, Rosemary Oliveira, Ofir Harari, Jamie I Forrest, Hinda Ruton, Sheila Sprague, Paula McKay, Alla V Glushchenko, Craig R Rayner, Eric J Lenze, Angela M Reiersen, Gordon H Guyatt, Edward J Mills,

Effect of early treatment with fluvoxamine on risk of emergency care and hospitalisation among patients with COVID-19: the TOGETHER randomised, platform clinical trial,

The Lancet Global Health, 202, ISSN 2214-109X, https://doi.org/10.1016/S2214-109X(21)00448-4.

(https://www.sciencedirect.com/science/article/pii/S2214109X21004484)

Abstract: Summary

Background

Recent evidence indicates a potential therapeutic role of fluvoxamine for COVID-19. In the TOGETHER trial for acutely symptomatic patients with COVID-19, we aimed to assess the efficacy of fluvoxamine versus placebo in preventing hospitalisation defined as either retention in a COVID-19 emergency setting or transfer to a tertiary hospital due to COVID-19.

Methods

This placebo-controlled, randomised, adaptive platform trial done among high-risk symptomatic Brazilian adults confirmed positive for SARS-CoV-2 included eligible patients from 11 clinical sites in Brazil with a known risk factor for progression to severe disease. Patients were randomly assigned (1:1) to either fluvoxamine (100 mg twice daily for 10 days) or placebo (or other treatment groups not reported here). The trial team, site staff, and patients were masked to treatment allocation. Our primary outcome was a composite endpoint of hospitalisation defined as either retention in a COVID-19 emergency setting or transfer to tertiary hospital due to COVID-19 up to 28 days post-random assignment on the basis of intention to treat. Modified intention to treat explored patients receiving at least 24 h of treatment before a primary outcome event and per-protocol analysis explored patients with a high level adherence (>80%). We used a Bayesian analytic framework to establish the effects along with probability of success of intervention compared with placebo. The trial is registered at ClinicalTrials.gov (NCT04727424) and is ongoing.

Findings

The study team screened 9803 potential participants for this trial. The trial was initiated on June 2, 2020, with the current protocol reporting randomisation to fluvoxamine from Jan 20 to Aug 5, 2021, when the trial arms were stopped for superiority. 741 patients were allocated to fluvoxamine and 756 to placebo. The average age of participants was 50 years (range 18–102 years); 58% were female. The proportion of patients observed in a COVID-19 emergency setting for more than 6 h or transferred to a teritary hospital due to COVID-19 was lower for the fluvoxamine group compared with placebo (79 [11%] of 741 vs 119 [16%] of 756); relative risk [RR] 0·68; 95% Bayesian credible interval [95% BCI]: 0·52–0·88), with a probability of superiority of 99·8% surpassing the prespecified superiority threshold of 97·6% (risk difference 5·0%). Of the composite primary outcome events, 87% were hospitalisations. Findings for the primary outcome were similar for the modified intention-to-treat analysis (RR 0·69, 95% BCI 0·53–0·90) and larger in the per-protocol analysis (RR 0·34, 95% BCI, 0·21–0·54). There were 17 deaths in the fluvoxamine group and 25 deaths in the placebo group in the primary intention-to-treat analysis (odds ratio [OR] 0·68, 95% CI: 0·36–1·27). There was one death in the fluvoxamine group and 12 in the placebo group for the per-protocol population (OR 0·09; 95% CI 0·01–0·47). We found no significant differences in number of treatment emergent adverse events among patients in the fluvoxamine and placebo groups.

Interpretation

Treatment with fluvoxamine (100 mg twice daily for 10 days) among high-risk outpatients with early diagnosed COVID-19 reduced the need for hospitalisation defined as retention in a COVID-19 emergency setting or transfer to a tertiary hospital.

Funding

FastGrants and The Rainwater Charitable Foundation.

Translation

For the Portuguese translation of the abstract see Supplementary Materials section.

Covid-19 pneumonia affects the brain by causing hypoxia and inflammatory reactions, leading to neurologic dysfunction. Mental health disorders may be partly caused by inflammation. Depressed persons may not protect themselves from Covid-19 because they’re apathetic and hopeless. It’s a two-way street. It’s like Dr. Wes Ely, MD, MPH says:

The lung bone is connected to the brain bone
E. Wesley Ely, MD, MPH

Moderna Booster Jab Today and Mindful Zombies

I got my Moderna Covid-19 booster jab this morning. That was quick. A guy (probably about my age, I’m not sure) waiting for his booster behind me chuckled and asked, “Did she even let you sit down for it?” I was in and out that fast. It’s the same as the primary series, only half-dose. Sena and I are now both fully vaccinated and boosted.

According to the FDA and CDC guidelines, I could have gotten a heterologous booster, but I stuck with what I got for my primary series. There was no problem with vaccine supply; it was already on the shelf, so the only thing different was the smaller dose. Since there’s not much else to say about it, we’ll move on to other more exciting news.

Sena ordered the Zombie cribbage game I just had to have. It won’t get here by Halloween, but that’s OK. I know the board is a folding plastic affair and there’s only enough peg holes for what would be half a full game (61 instead of 121). The pegs are zombie figures—which may or may not fit in the holes.

But it’s zombies! This is what happens to you in retirement, people. My gratitude to Sena for getting Zombie cribbage will be to play Scrabble with her.

That reminds me of a cribbage story I read on the web about a game between a couple of old guys in a senior community in Minnesota. One of them, Harry, was 108 years old and the other, Don, was 105. They were long time cribbage players, but they’d never played each other. The young guy won. As soon as he did, he got back on his walker, saying, “Just another game,” and left. In fact, neither player got as excited about the affair as everyone else including spectators, family, and staff, talking it up like it was a championship boxing match. Don’s family said that his attitude about the win was probably part of the reason for his longevity.

I liked Don’s reaction to winning the game. I don’t know if Don’s approach to cribbage is the same as it is to life in general. Maybe it’s about living in the present. When something is over, it’s in the past and it’s time to move on. There’s probably no point in worrying about the future either, especially when you get pretty old. There’s not much of it left.

Maybe this mean that retirees should be more like zombies—we should just play cribbage, eat brains mindfully, and forget about tomorrow. You’re welcome.

Can Cribbage Cultivate Congeniality?

Sena and I have been playing cribbage since late 2019. It’s a two-hander card game played on a board with pegs for keeping score. It’s been around for about 400 years and some have asked whether it’s a dying game, played mainly by codgers in retirement homes. The question is whether it can promote positive attributes like congeniality.

Actually, it’s a pretty popular game, especially for, some reason, in California where there are over 40 local cribbage clubs according to the American Cribbage Congress (ACC), the big boss organization in North America, established in 1980. Most states in the U.S. have only a few. Iowa has one in Ankeny.

If you look at the ACC website, you’ll find a section called the ACC Cribbage Club Code of Congeniality. It’s under the Clubs section. The wording is in some ways a bit ambiguous, probably because many of the members are very competitive. There are a lot of tournaments, including an annual Grand National. The most recent one was held in Sacramento in late September, just last month. Even though it’s a pretty big deal, attracting players from just about everywhere on the planet and possibly beyond, I can’t find out who the winner was from the website. Maybe that person is too congenial to brag.

Anyway, the ACC Code of Congeniality has a tone, for lack of a better word. For example, take this item:

“We pledge to not force new players to play a game in fifteen minutes. (We will, instead, be tolerant and not complain, remembering that we too, started slow.”)

Sena and I never can finish a game in 15 minutes, and we’ve been playing for going on a couple of years. That pledge as well as the others have an almost Mark Twain-like ring to them. It’s as though whoever wrote it was snickering behind her hand. Or maybe the ACC leadership got wind of a few complaints from new members who got horsewhipped for dragging the games out to 17 minutes or even longer. Actually, it’s the subtle sense of humor expressed in the Code of Congeniality that I appreciate.

The ACC also has a Code of Ethics which extols “true sportsmanship and respect for others, without rancor, animosity, or overwhelming self-interest during competition.”

The ACC publishes its tournament rules and it is to be contrasted with something called kitchen table cribbage. Except on my blog and YouTube video, you’re unlikely to find the term Kitchen Table Cribbage anywhere on the web.

There was a man named Peter Worden who traveled around the world, teaching people how to play cribbage, love it, and make new friends. His short documentary about his travels and adventures is called the Cribsionary. A photograph shows him hiding his face with his cards—I don’t know why. He says cribbage is 50% luck and 50% skill. There are those who have different opinions about that. He also says he likes the quotation:

It’s easy to agonize over such situations but quite profitless; sometimes one is faced with a scattered collection, at other times there’s an embarrassment of riches.
Peter Worden?

I could not find this quotation in its entirety anywhere on the web. Well, I found the “embarrassment of riches” part, the authorship of which seems to be in some doubt. This seems to capture how one feels about the hand one is dealt in a cribbage game—and perhaps in life. He doesn’t take credit for the quote, but I’m going to take a chance and give it to him.

Cribbage is a lot of fun and there are variety of handsome and even whimsical boards on which to score your points. The ACC prefers a special board for tournaments which makes it easier to avoid pegging mistakes.

We prefer a jumbo board (bigger numbers and pegs), but have played on one shaped like the number 29, the highest score you can make. The odds of getting that hand score are 1 in 216,580. You want to keep playing just to see if you ever get it. You’ll have a lot of fun on the quest.

It might also be a way to foster congeniality in society. We sure need it.

Catatonia and Delirium in COVID-19

This is just a short post on delirium and catatonia in patients sick with COVID-19, which is important to look out for. There are two references below that are pertinent. One is a case report of a patient diagnosed with both catatonia and delirium in a woman with COVID-19 (Amouri et al). One of the co-authors is critical care intensivist, Dr. Wes Ely, Every Deep-Drawn Breath. Anecdotally, when Dr. Ely gave his talk on delirium at an Internal Medicine Grand Rounds presentation on April 12, 2019, I asked him what he thought should be the role of the consulting psychiatrist’s role in ICU delirium. He seemed to remember me and said we would be helpful in identifying the catatonic variant of delirium. What is ironic about this is that, while benzodiazepines are known to cause delirium, they can treat reverse catatonia in the setting of delirium and other neuropsychiatric and medical conditions.

The other article (Baller et al) is an excellent summary of pharmacological recommendations for delirium associated with COVID-19. There’s a nice pharmacologic treatment algorithm on page 589.

References:

Amouri J, Andrews PS, Heckers S, Ely EW, Wilson JE. A Case of Concurrent Delirium and Catatonia in a Woman With Coronavirus Disease 2019. J Acad Consult Liaison Psychiatry. 2021 Jan-Feb;62(1):109-114. doi: 10.1016/j.psym.2020.09.002. Epub 2020 Sep 15. PMID: 33069380; PMCID: PMC7491455.

Baller EB, Hogan CS, Fusunyan MA, Ivkovic A, Luccarelli JW, Madva E, Nisavic M, Praschan N, Quijije NV, Beach SR, Smith FA. Neurocovid: Pharmacological Recommendations for Delirium Associated With COVID-19. Psychosomatics. 2020 Nov-Dec;61(6):585-596. doi: 10.1016/j.psym.2020.05.013. Epub 2020 May 21. PMID: 32828569; PMCID: PMC7240270.