ALUMINUM – IS IT A BRAIN TOXIN ?

Steven Lippmann, M.D. Emeritus Professor, University of Louisville School of Medicine 

For decades there have been concerns about whether aluminum is toxic for humans. Does it cause dementias? No conclusive answers, but many people have gotten rid of aluminum cookware, despite still using aluminum foil. Lots of us remember the past frequency of pots and pans made of aluminum. There were questions about whether aluminum incorporation into the body, by oral or dermal means, might induce cognitive declines or other neurological conditions, like parkinsonism, autism, or others.           

There are investigations suggesting that aluminum toxicity is related to early-onset dementia of an Alzheimer disease-like state. However, other research documents no clear etiological leakage. Studies provide no definitive answer. There is much speculation, but a literature review leaves one realizing how little we truly understand. Exposure is widespread because aluminum is the third commonest element in the earth’s crust, and thus, it is in our food supply, medications, and cosmetics.           

Aluminum, in acceptably low levels, is naturally present in many fruits, vegetables meats, fish, and cheeses, etc., but without noting dangerous consequences. Toxicity from this is not recognized. In addition, aluminum is used to facilitate some food preparations like in baking and/or pickling. Baking powder is one of the ingredients of concern, but fortunately aluminum-free baking powders that only contain sodium bicarbonate are ubiquitously available and safe. Exposure can also come through water purification processes and might leach into beverages via aluminum can containers.           

There are many industrial and medical applications. Besides widely available aluminum containing antacids, its hydroxide can also be a vaccine adjuvant. Fear of vaccines has long been an issue; yet, not all vaccines contain aluminum. Our currently available COVID-19 vaccinations contain no aluminum; good news now adays during this pandemic. Reportedly, there is no aluminum in Pfizer, Moderna, Johnson & Johnson, or AstraZeneca vaccines.           Aluminum has antibacterial and antiperspirant qualities, thus it is present in some underarm odor-suppression products. Antiperspirants diminish sweating and that differentiates them from deodorants. Some cosmetic and skin care products also contain aluminum traces, and that also includes styptic pencils or powders, because of their potential to diminish bleeding from small abrasions or cuts, like from razor shaving.           

What about the safety of antiperspirants that contain aluminum? Some marketed products, state clearly up-front in bold lettering that they do not contain aluminum chlorohydrate. That prominent disclosure is sometimes followed in small print on the back label, saying that this product contains potassium alum. Yes, alum is an aluminum salt with potassium, sulfate, sodium, or ammonium. Potassium alum is sometimes called potash alum, proclaimed to be safe, and used in place of aluminum chloride or chlorohydrate.Apparently, this form of chlorohydrate is a small molecule and is easily absorbed through skin, while alum is larger and is thus with less dermal penetration. The implications of these statements opens a question because the product labeling appears to be deceptive. It seemed that the marketers want to convey that their product contains no aluminum and counts on people not reading or understanding potassium alum’s relationship to this metallic element. It might still be safe, but the product labeling prompts concern.           

The pathophysiology of many neurodegenerative conditions remains unknown and proven aluminum toxicity is not obvious. One possible explanation from some sources suggests that aluminum-induced dementias may be due to a physiological predisposition to retain aluminum in the body and/or brain. Thus, vulnerable persons might become toxic while other people evidence no ill effects. However, anyone with a family history of early-onset dementia, probably ought to diminish aluminum exposures.           

Despite lack of clarity about brain toxicity, there are ways to reduce exposures. One can easily avoid aluminum-content antiperspirants, not employ aluminum cookware, even not cooking in its foil form, and not using aluminum-containing baking powders, antacids, and/or vaccinations. Patients and the public should be made aware that no current COVID-19 vaccinations in this country contain aluminum. Also, let people know that many popular antacid tablet brands contain aluminum salts, but calcium carbonate alone and/or with magnesium salt alternative antacids are very widely available. More difficult to identify and harder to rule out is exposure through packaged, prepared baking products. This may not be a major concern, but the degree of presence and risk is not widely known.           We should not become preoccupied with an unproven toxicity, but there are reasonable precautions to minimize adding high aluminum exposures. Time may settle this issue. For now, rely on awareness and prudence.

Telemedicine and COVID-19


Telemedicine technology has been around for a few decades but it was never optimally utilized until the COVID-19 pandemic. Insurance reimbursement was a big barrier in utilizing telemedicine along with other systems barriers. In March 2020, COVID-19 was declared a pandemic by WHO. After this, telemedicine was considered the preferred modality of treatment in the health care industry, and insurance supported the use of this technology. This was a big change for all of us as physicians. We all had to adapt to this new technology within days. This transition had its pros and cons, there was a lot of uncertainty about the usage of telemedicine at that time. When the pandemic started, we were worried if we would be able to continue to safely provide care for our patients or not. With telemedicine as a preferred modality, several of us started working from home. It’s been more than a year now since we have been doing Telemedicine and it has been an interesting experience. Some of us love it and some not so much.


Now most of us are comfortable with this technology and some of us prefer virtual over in-person visits. We never thought that we would be able to build therapeutic rapport and feel connected with patients via telemedicine but I have to say that I feel connected. Research supports this as well. A systematic review by Guaiana and et al published in October 2020 in the Community Mental Health journal showed that the efficacy of Telemedicine and in-person visits were similar (1). Several patients prefer using Telemedicine over in-person visits. There are several advantages of Telemedicine visits. From the patient perspective, 1) They can overcome the geographical barrier and save the transportation cost. 2) They don’t have to worry about bad weather. 3) Several patients are very anxious about waiting in the doctor’s office so they like virtual visits. 4) Mobility is another barrier. As with any technology, there are disadvantages of telemedicine as well. Some patients don’t have access to video technology, some patients are not tech-savvy and it intimidates them to use this platform. As physicians, we see several advantages and disadvantages as well. One of the biggest advantages has been the ability to continue patient care during the COVID- 19 pandemic. Patients’ show rate has been better as compared to in-person visits. Psychiatry is more equipped to do Telemedicine as compared to other specialties where physicals are needed to diagnose and treat patients. With the COVID-19 pandemic, research is showing worsening of mental health so demand for mental health treatment is increasing. Maxime. T et al did a retrospective cohort study on 236379 patients who were COVID survivors. They found out that estimated evidence of neurological and psychiatric diagnosis was 33.62 % in the following 6 months post-COVID (2). 


At this time Telemedicine continues to grow in Psychiatry but we still don’t know what would be the future of Telemedicine once the COVID-19 pandemic is over. Will we as physicians and our patients struggle with virtual “ fatigue” or will we continue to like this? Will this pandemic be over or is COVID- 19 here to stay? Will this be a “ new normal” or not? It is hard to answer these questions at this time. It would be appropriate to have a hybrid model where patients and physicians can have the choice to have either virtual or in-person visits depending on what’s best for the patient. As with any other decision-making in health care, we have to weigh the risks and benefits and make our best decision. 

 References-1.Guaiana, G., Mastrangelo, J., Hendrikx, S. et al. A Systematic Review of the Use of Telepsychiatry in Depression. Community Ment Health J 57, 93–100 (2021). https://doi.org/10.1007/s10597-020-00724-22.6-month neurological and psychiatric outcomes in 236379 survivors of COVID-19: a retrospective cohort study using electronic health records Maxime Taquet, John R Geddes, Masud Husain, Sierra Luciano, Paul J Harrison 

Ruchita Agrawal MD, FAPA
Board Certified Adult Psychiatrist
Associate Chief Medical Officer Adult Services
Seven Counties Services
708 Magazine Street
Phone no. 5025898926
Assistant Professor U of L

COVID-19: Medical Issues and Responses

by Robert Frierson, M.D. & Steven Lippmann, M.D.

The SARS-CoV-2 virus emerged causing a worldwide pandemic in 2019. Many people in Louisville and the rest of Kentucky were infected during 2020 by its illness, called COVID-19. The population was worried and that bothered the healthcare community, including doctors. Robert Frierson decided in 2020 to formally poll his local physician colleagues about their concerns and hear what they suggested doing about it. 

Doctor’s feared exposure to the virus, transmitting COVID-19 to family members, and/or getting sick themselves; that emerged as one of the initial issues. There was disappointment by all healthcare personnel and the general public about insufficient supplies of personal protective equipment (PPE), even of facial masks or routine gowns. It seemed that we were not response-prepared for this type of viral contagion. Physicians were concerned about diminished ability to be in close clinical contact with patients nor with other medical personnel; families were blocked from visiting relatives, even during emergencies or terminal situations. Patients were even more upset by these separations, and these factors had a negative impact on hospital and clinic staff resilience and morale.

Rates of addiction and psychiatric presentations escalated along with affective illness and overdoses; many people with somatic conditions, fearful of COVID-19, also avoided medical contacts and were suffering from increased and untreated pathology. Societal apprehension concentrated on problems of quarantining with social distancing, along with concerns about employment, education, and unstable or inadequate life-style.

Questioning then focused on what to do about these issues. Doctors reported that talk-time with colleagues and extra consideration in dealing with healthcare personnel was beneficial. Maximizing social connectedness and advocacy in all spheres possible was helpful. They also focused more on enjoying support from the wider community at their “front-line” efforts and took gratification from providing effective healthcare. Also helpful was avoiding overly subscribing to COVID-19 news reporting. Caring for oneself was another benefit: assuring good rest, diet, exercise, balance with family time, and related matters. These responses lead to more satisfaction throughout the medical community and everyone, despite a continued pandemic. Hopefully, it facilitates effective administration of optimal health care for the remainder of the COVID-19 pandemic.

Challenges and Hopes in the COVID era:

For many of us, 2020 was pretty rough, with lots of unpredictability, uncertainty, fears and losses in different shapes and forms all around the world. Not knowing which direction to go and how to keep patients, families, and ourselves safe, was quite a challenge. We all had traumatic experiences at different levels taking care of patients and losing colleagues who were first line responders to COVID.

We all witnessed racial and ethnic disparities, massive unemployment, and protests. As per one of the JAMA articles, “The resurgence of anger at long-standing racism and racial inequities was added to the anxiety and tension of the pandemic, creating a combustible scene of national civil unrest.” There is so much we can talk about in the year 2020, but the good news is that year has concluded.

Changing the calendar is a very traditional and emblematic experience for me every year, learning from the past 12 months and moving on to the next 12 months with new hopes, is a wonderful opportunity to reconstitute the year ahead. As we are all stepping into the new year of 2021, we are starting to see a light at the end of the tunnel.

As Psychiatrists, we tend to see things more optimistically. Although the pandemic is still here, and now with the challenge of a more virulent strain and a rise in COVID cases, we are remaining positive (not covid positive 😊). The KMPA has always been standing upfront for our colleagues and patients’ mental health during this era of COVID. I call the era of COVID, an era of technology. KPMA has been very active and well connected during this phase by utilizing technology.

This year, mental health issues are skyrocketing. There is an increase in severity of existing cases but many more new cases. The increase in mental health issues in medical professionals is directly due to dealing with COVID deaths of their patients, long hours at work, risking their own lives, staying away from their families, etc. However, KPMA has provided colossal support to colleagues. Whether they are practicing inpatient, outpatient, university-based, or community-based practices, the KPMA was able to keep everyone updated with new and crucial changes throughout the year and arranged webinars and weekly meetings for the COVID-19 task force.

KPMA is well aware that the contemporaneous good news of the COVID vaccine being on board and still rising COVID cases has caused conflicting emotions at this point, but we are still optimistic and will continue to provide support to our colleagues for future challenges.

At this point, we do not know how the post vaccine world will look like. We are all aware that we have to be more flexible to the new changes and the improvements.

I would like to share this phrase that I read, “There’s always times when we think we can’t manage another minute, and then we do…..We just keep going.”

Stay safe and healthy!

Best Regards, Sajida Zubi Suleman, MD, DFAPA Vice President, KPMA

Update on Kentucky’s Psychiatry Residency Programs

University of Kentucky by Dr. Sandra Batsel-Thomas

It is an exciting time of growth for the University of Kentucky Psychiatry Residency Program.  We started a new Integrated Child and Adolescent psychiatry track this year that allows applicants to match into the Adult Psychiatry and the Child Psychiatry Fellowship at the same time.  It also allows for more training in pediatrics and pediatric neurology.  The first two interns started in this track in July.   We also are staring recruiting this year for our newly improved  5 year combined Internal Medicine/Psychiatry Residency Program.  This will have 2 residents a year and will be a great complement to our Triple Board residency program.

We had 8 new interns start in our various residency programs this July.  We have 4 in our categorical program, 2 in the Integrated Child and Adolescent Psychiatry track and 2 in our Triple Board program.  We also had 4 new child and Adolescent Psychiatry fellows and one new Addiction medicine fellow start in July.  In our Categorical Psychiatry program and Integrated Child track we are holding true to our mission to train psychiatrists who want to stay and practice in the region.  Of our new interns – three are University of Kentucky COM graduates, one is a graduate of the University of Pikeville COM, one Lincoln Memorial University-DeBusk COM in Harrogate TN and one is a Kentucky native and a graduate or St. George’s University School of Medicine.

University of Kentucky @ Bowling Green by Dr. Todd Cheever

The University of Kentucky College of Medicine started a Psychiatry residency program in Bowling Green, Kentucky in 2016. Currently, there are twelve residents in the general adult program. At the conclusion of this past academic year, two residents graduated from the program. Both are now working in Tennessee as adult psychiatrists. Two residents were accepted into Child & Adolescent fellowships programs – one at the University of Colorado in Denver, and one at the University of Kentucky in Lexington.

University of Louisville by Dr. Geoffrey Jeyasingham & Dr. Greg Wykoff

The University of Louisville Psychiatry Residency Program began its new academic year in July and welcomed nine new PGY-1 residents to the program. The program completed another successful match and filled all nine available positions. The new intern class is comprised of five females and four males. Six of the nine are US medical school graduates and four have already passed their USMLE Step 3 exam. The average Step 2 score of the class is, once again, well above the national average for incoming Psychiatry interns. We have thoroughly enjoyed working with our interns thus far and anticipate they will continue to prove a wonderful addition to our department.

Although the pandemic has certainly affected our lives both at work and at home, our residency program has continued to prioritize residents’ education. To do so, our program has transitioned from weekly in-person didactics to virtual learning experiences via apps such as Zoom and BlueJeans.  This transition began in early March and has continued through the Summer and early Fall.  To accomplish this, residents have taken a greater leadership role in teaching their peers and facilitating a more active learning environment. While there certainly are some elements that are missed from the on-site learning experience, virtual didactics have provided several benefits.  Among these are increased safety and convenience, as well as improved opportunities for collaboration.

Finally, the program has continued to embrace the role of telepsychiatry and telemedicine in providing patient care. The University of Louisville has been at the forefront of implementing and utilizing telepsychiatry services for patients throughout the state of Kentucky for many years, and this history has proved to be very helpful in adjusting to a primarily telepsychiatric clinic. We anticipate that our program will continue to prepare residents to provide outstanding psychiatric care both in person and virtually as the practice of Psychiatry continues to evolve.

 Regarding community outreach, our program is excited to announce we have a new partnership with Park Duvalle that will allow PGY-3 residents the opportunity to work closely with an underserved and historically marginalized portion of the community.  We anticipate that this experience will help our residents to gain a greater appreciation for outpatient care at the community level, and feel experience at Park Duvalle will strongly complement other clinical experiences at the University of Louisville and Veterans Hospital.  

Overall, we feel that despite the many unanticipated setbacks related to the Covid pandemic, University of Louisville is well-situated to continue to adapt to the rapidly changing landscape of modern psychiatry.  We continue to attract an increasingly strong pool of applicants for residency and are working to improve the quality and variety of our clinical experiences, including our long history of promoting telepsychiatry and virtual learning.  As such, we believe the future of U of L Psychiatry to be bright, and believe things will continue to improve as time goes by, even in these uncertain times.