Celebrating in the Big Apple! Sheldon P. Wagman, DO, DLFAPA, was honored at the Convocation of Fellows with the distinction of Distinguished Life Fellow of the APA.  

Allen Kayser, MD, DLFAPA, previously awarded Distinguished Fellow, was honored at the Convocation of Fellows with the additional distinction of Distinguished Life Fellow of the APA.  
Other celebrated members, we welcome your photos from the APA Annual Meeting.  Please send them to 
NYC Skyline - Favorite Sight from APA Annual Meeting.
Summer Greetings!
Monica Taylor Desir, MD, MPH              August 2014
Newsletter Chair

Welcome to the first green newsletter for the Arizona Psychiatric Society.  I am honored to have the opportunity to serve the Arizona Psychiatric Society and my fellow colleagues in the position of the Newsletter Editor.  As we pulled together this Summer Newsletter, I am struck by all of the accomplishments of our members from the Distinguished Life Fellows, to Dr. Lane, our Howard E. Wulsin Excellence in Education Recipient, to Dr. Coons, the recipient of the 2014 Career Achievement in Psychiatry award, to the exciting contributions of our residents.  Arizona has a great community of psychiatrists, and I am looking forward to a year of documenting our accomplishments, challenges, and experiences.  Also in this issue, Dr. Robin Reesal, our former Newsletter Chair shares what he is doing in this current chapter of his life in Rwanda.

In addition to these member highlights, the Newsletter offers some great information on Integrated Care Risk Management, and when do you need prior patient authorization in the communication of patient health information; important Arizona behavioral health updates from the Director of ADHS regarding recent court decision on medical marijuana and PTSD, and the Greater Arizona RFP process; reports from the APS and APA Annual Meetings, the INES Annual Meeting, and the ArMA House of Delegates; Assembly and Legislative Reports; information regarding local and regional CME opportunities and APA Free CME; with reminders about the Sunshine Act deadlines, fellowship, and a repeat of the link to submit your comments regarding the Greater Arizona Behavioral Health RFP Survey.  Of note, the early bird registration deadline for the UofA Department of Psychiatry four-day conference is August 31st, and the deadline to complete the survey for comments on the RFP is August 20th.  

We welcome your contributions, questions, comments and interests.  Please share this newsletter with your colleague.  We hope to see you at one of our upcoming events.  Coming up,
 we hope to see you at the Fall Social and "Why Advocacy Matters" Mixer in Tucscon at Kitchen Bodega and Wine on September 18 and in Phoenix at Phoenix City Grille on September 30.




President's Message
Dr. Sadr presents Dr. Kowalik with a Presidential Service Award from the Society at its Spring Annual Meeting
Payam Sadr, MD, FAPA
Arizona Psychiatric Society President

It is my pleasure to serve as the President of the Arizona Psychiatric Society.  I thank Dr. Kowalik for her thoughtful leadership of the Society and for working to improve our connection to one another, at all career levels, and I hope to build upon the accomplishments of the Society in that regard.  I would also like to recognize the crucial contributions made by the Council Members, Executive Officers, and Executive Director, Teri Harnisch, who have served and continue to serve the Society in such a selfless manner. Thanks to each and every member who has given of their time and energies to the Society.  

These first months as President have been busy, and the weeks ahead promise to be even more so, with opportunities to provide feedback on the Greater Arizona RFP for the Regional Behavioral Health Authorities; working with community partners for the provision on behavioral health services on how to more effectively partner together; outreach to the residency programs; the Fall Social and Why Advocacy Matters events in Phoenix and Tucson; and planning for the Spring Annual Meeting.  Drs. Carol Olson and Edward Gentile attended a training session with the APA over the summer on many aspects of the Affordable Care Act and Health Care Reforms, and we will be working with them to bring educational events to the Society on related issues.  

Finally, we will soon know if the Psychologists for Prescribing Privileges will submit proposed legislation through the presentation of a Sunrise Application, the deadline for which is 
September 1, 2014.  Please watch for Arizona Psychiatric Society e-mail alerts on the topic.  There have been recent material changes in the debate over psychologists prescribing with the recently enacted Illinois statutes, which provide a path for psychologists to prescribe, with specifically defined live biomedical education, for a limited population, and under appropriate supervision.  

The Society recently contributed support on the issue of veterans' reforms, writing to Senator McCain and Representative Kirkpatrick asking for their consideration of the Ensuring Veterans Resiliency Act when coming to the table on the topic of veterans health care reforms.  Drs. Roland Segal and Elaine Ramos signed off on an op-ed that was featured in The Arizona Republic on this topic.  

There are many ways for us to connect, be involved, support one another, and advocate for our profession and our own behavioral health community of patients and providers.  Thank you for taking the important step of being a member of the Society.  If you are interested in becoming more involved on any topic, please contact me or Teri (  I hope to see you on September 18th in Tucson or on September 30th in Phoenix for the Fall Social and Why Advocacy Matters receptions.  

Making a collegial connection at the Annual Meeting Friday Evening Social, From the Left:  Drs. Espinoza, Thienhaus, Gesmundo, Kafer, Victor, Sadr, Aminian, and Karbakhsh.
Traveling from Tucson and California for the Friday Evening Social, From the Left: Drs. Lane, Weihs, Curry, Chhatwal, and Maldonado.
Report from APS Annual Spring Meeting
Richard D. Lane, MD, PhD, DFAPA, was presented with the Howard E. Wulsin Excellence in Education Award by
Ole J. Thienhaus, MD, DLFAPA, on behalf of the Society, and is seen here celebrating the return home to University of Arizona with those accolades. Dr. Thienhaus was recognized as well with a President Recognition Award from the Society.
Reconnecting; Excellence in Education; and Celebrating Our Best at the APS 2014 Annual Spring Meeting

Thank you to all who attended the Arizona Psychiatric Society Annual Spring Meeting on Saturday, April 12, 2014, with the theme "Changing the Practice and Perception of Psychiatry:  Delivering Optimal Care in an Integrated Setting."   Thanks to the planning efforts of the Education Committee, Drs. Joanna Kowalik (Chair), Gretchen Alexander, Michael Brennan, Emerson Bueno, Amie Kafer, Payam Sadr, Monica Taylor-Desir, and Ole Thienhaus (with AACAP representatives, Drs. Elise Leonard and Kytja Voeller), the Annual Meeting featured a rich and diverse educational program.  

The Annual Meeting also offered the opportunity to celebrate important contributions to psychiatry from our members.  The Howard E. Wulsin Excellence in Education Award was presented to Richard D. Lane, MD, PhD, DFAPA, of the University of Arizona College of Medicine, Department of Psychiatry, making Dr. Lane the tenth annual recipient of this distinguished award.  President Joanna Kowalik presented Presidential Distinction Awards to each of Ole J. Thienhaus, MD, DFAPA, and James B. McLoone, MD, DLFAPA, in recognition of their distinguished service in bringing the DSM-5 Workshops to our membership, and also to Gretchen B. Alexander, MD, for her continued leadership in the Society and the Arizona Medical Association, advocacy, and support of psychiatry, and continued pursuit of excellence in psychiatric care.  The Society is proud to begin the tradition of the Career Achievement in Psychiatry Award, and celebrated the life-long contributions of David J. Coons, MD, DLFAPA, whose award was accepted on his behalf by Dr. Elizabeth Kohlhepp (Read more about Dr. Coons in the feature authored by him in this Newsletter's "Meet Your Fellow Member.")  Also beginning a new tradition, the Society honored Residents of the Year, as nominated by their own Programs.  These three Resident-Fellow Members of the Society have made great contributions to the leadership of the Society in their early years as members and are well deserving of the recognition:  Felicitas Koster, DO, Maricopa Integrated Health Systems Psychiatric Residency Program; Matthew Goldenberg, DO, Banner Good Samaritan Medical Center Psychiatric Residency Program; and Jason Curry, DO, University of Arizona College of Medicine, South Campus Psychiatric Residency Program.   For 2013, the Arizona Psychiatric Society was awarded the American Psychiatric Association Member Communications Award 2013 e-Newsletters for effective communications with APA members and external audiences on matters of importance to psychiatry.  In recognition of his leadership and contributions in developing and overseeing the Arizona Psychiatric Society Newsletter, as Newsletter Committee Chair, the Society shared this recognition with Robin T. Reesal, MD.  

This great day of education and collegiality included the following presentations by local and national authorities in their fields:  "Alzheimer's Prevention:  Pipedream or Possibility?," Pierre Tariot, MD; "Integrated Mental Health Care:  Closing the Gap Between What We Know and What We Do," Anna Ratzliff, MD, PhD; "Mood Dysregulation in Children:  What's Bipolar and What's Not," Steven R. Pliszka, MD; Legislative Update -Joseph F. Abate, Esq., APS Lobbyist; "Update from State of Arizona Division of Health Services - Behavioral Health Services."  Steven Dingle, MS, MD; "The Times They Are A-Changin': How Re-conceptualization of Disease is Transforming Medicine; Implications for Psychiatric Treatment and Research" - Pedro L. Delgado, MD; "Pathopsychology of Alcohol Withdrawal:  Novel Treatments Beyond Benzodiazepines." José R. Maldonado, MD, FAPM, FACFE; and "Palliative Care and Psychiatry:  Providing Supportive Care to the Palliative Patient" - Karen Weihs, MD.  The Society is proud to make this Annual Meeting available to its members.  Needs assessment and planning is underway for the 2015 Annual Meeting on the theme of early interventions in psychiatric care.  If you have a specific request for a topic or speaker on this theme, please contact Teri (, 602-347-6903).  
Gretchen Alexander, MD receives a Presidential Recognition Award from Dr. Joanna Kowalik for her continued support, mentorship, and advocacy for the field of psychiatry.
James B. McLoone, MD, DLFAPA was presented with a President's Recognition Award for his extra efforts in connection with the DSM-5 Trainings.
October 2014
Integrated Care:
Working at the Interface of Primary Care and Behavioral Health
edited by Lori E. Rany, MD

CLICK HERE for a printable order form and additional information on this new guide, which defines integrated care, reviews the evidence base, and addresses the three potential benefits of this model of care:  improved outcomes, cost containment, and enhanced patient experience, or visit to order this book online (APA members receive a discount of 20% and RFMs get a 25% discount when ordering online).  APS is working with Dr. Raney to coordinate featuring an exerpt in an upcoming Society Newsletter. 

Meet Fellow APS Member:  David J. Coons, DLFAPA
David J. Coons, MD, DLFAPA, Stops to Smell the Flowers: Hilda Klager Lilac Garden, Woodland, WA
Dr. Coons was chosen to be the first recipient of the Arizona Psychiatric Society Career Achievement in Psychiatry Award, and he takes the time here to reflect upon that career and the meaningfulness of the recognition to him personally.

In April, when the Arizona Psychiatric Society honored me with the 2014 CAREER ACHIEVEMENT IN PSYCHIATRY AWARD, I was surprised and amazed, followed closely by being humbled. The award actually honors the contributions of dozens of people: mentors, residency mates, peers, students, supervisors, and patients. Since I can't begin to name all those who helped me along the way, I won't specifically identify any - you know who you are. Well, maybe I should mention my wife of nearly 44 years and three great "kids."

Forty years ago I entered psychiatric residency in Phoenix at "Good Sam" after graduating from the University of Utah College of Medicine. An elective rotation in psychiatry during my internship had introduced me to the Samaritan program, and I loved it. My residency peers and my mentors in the program were unique, and even amazing. Their influence helped me develop a practice that eventually spanned public and private sectors. Over these years, I was able to work in inpatient, outpatient, forensic psychiatry, administrative medicine, supervision and teaching positions in both Alaska and Arizona. I stumbled into writing laws in two states and had several shots at program development. There was rarely a dull day, and some days were downright frightening.

Let me recount one project that illustrates the joy of being in the right place at the right time with the right people. It is also a reminder of how even the most successful interventions are fragile and may collapse. In the late 1980s, I was contracted by the Arizona State Hospital leadership to help bring the hospital into compliance with federal and joint commission standards. The hospital was a mess, but a team of top quality people had started to accumulate, and a slow but steady transformation began to occur over months, then years. Quality improvement ideas were brought in and gradually embraced. The hospital began to be recognized as a leader and the joint commission raved about the performance improvement system. The hospital ended up earning an unheard of survey score of 100!

Little did we know that a bomb was about to drop. A previously planned, secret staff cut was unleashed within weeks of the "perfect score." Patient care began to suffer and before long the place was turning into a nightmare. That was when the medical staff stood up. I have never been prouder of my profession or my colleagues. Psychiatrists risked their jobs to go public and take on those who were dismantling the programs and staffing. We had the data to show the damage caused by the cuts and enlisted the hospitals advisory board and the press. Suddenly, this became a national story. The hospital's federal funding was blocked because of the deteriorating care. That caught the politicians' attention, and the crisis was finally addressed. Much was restored and staffing was even improved. Sadly, many good people had moved on and there was no chance of returning to the mental health Camelot of which we had once dreamed.

Large health organizations, both public and private, are always flawed, but we can sometimes step out of our treatment roles and improve a whole system even in the face of powerful political opposition. So, was that battle worth it? Absolutely!

So what now? My interests have always been pretty diverse. I am now taking the chance to spend more time on genealogy, hiking, tennis, traveling, reading, writing, music and grand-parenting. I have almost given up dragon slaying, but let us all be ready to jump in when the dragon appears again.

I could not appreciate this award more. I will always treasure it.  Thank you.

SIGN-UP TODAY - Tucson (September 18) and Phoenix (September 30):  Fall Social and "Why Advocacy Matters"
J&J and Janssen Logo

Hosted by corporate sponsor, Johnson & Johnson Health Care Systems, we hope you will plan to join fellow Society members at a Fall Social Reception and "Why Advocacy Matters" presentation to be held in Tucson on September 18, 2014, at Kitchen Bodega & Wine, and in Phoenix on September 30, 2014, at Phoenix City Grille, 6:30 to 8:30 p.m. on each evening.  

The event is free to all members.  Members may bring a guest if the guest is a physician or behavioral health care provider.  The evening will include social reception and a brief presentation on "Why Advocacy Matters," followed by a chance to speak with APS Lobbyist, Joe Abate, or other representatives of the Society's Legislative Committee.  Take Action Today!


You may also reserve your space by e-mailing Teri ( or calling 602-347-6903. Please provide your name, practice address, and e-mail address.  You may also visit the Society website for registration information.  Thanks to the corporate sponsorship, this event is free to our members, but is subject to Sunshine Act reporting.  Any direct employees of the Federal or State government should indicate so in their registration and the Society will sponsor their meeting costs in order to comply with sponsorship regulations.  Hope to see you there!
Communicating Protected Health Information - When Do You Need Prior Patient Authorization?[1]
By Kristen Lambert and Moira Wertheimer of AWAC Services Company ("AWAC"), member of Allied World Assurance Company Holdings, AG ("Allied World") 

Allied World, through its subsidiaries, is a global provider of innovative property, casulty, and specialty insurance and reinsurance solutions, offering superior client service through a global network of offices and branches.  Allied World is the APA-endorsed carrier through its strategic relationship with the American Professional Agency, Inc.  This is the first of a two-part article on risk management factors that relate to integrated care.  

Federal and state privacy laws, most notably HIPAA, directly impact the sharing of protected health information (PHI) among mental health providers.  HIPAA establishes national standards that provide patients with protections and control over the use/disclosure of their PHI. It is, however, important to remember that in addition to HIPAA, federal laws governing confidentiality of records involving mental health and substance abuse treatment, state confidentiality statutes and professional ethics standards may provide additional and more stringent protections than is required under HIPAA.  As such, psychiatrists must ensure that their patient privacy practices adhere to all applicable federal and state privacy regulations, as well as professional ethical standards. 


Privacy regulations generally attempt to strike a balance between protecting health information privacy while recognizing that disclosure may be necessary at times to protect the safety of the patient or third parties.  Striking this balance may be tricky for psychiatrists given the sensitive nature of the information at issue.  Whenever possible, providers should obtain patient authorization prior to disclosing PHI.  Even so, a frequent question that arises is "when and under what circumstances is it permissible for psychiatrists to disclose PHI without prior authorization?"[2]



Under HIPAA, health care providers are permitted to disclose PHI without prior patient authorization for ".....treatment, payment, and health care operations." "Treatment" generally means the provision, coordination or management of health care and related services among health care providers or by a health care provider with a third party, consultation between health care providers regarding a patient, or the referral of a patient from one health care provider to another as long as all providers have/had a relationship with the patient and the PHI disclosed pertains to the relationship.[3]

Additionally, under HIPAA, patients have the right to request restrictions on how a provider will use and disclose PHI about them for treatment, payment, and health care operations. Providers are not required to agree to a patient's request for a restriction, but are bound by any restrictions to which they agree.[4]  Any use or disclosure of PHI for treatment, payment, or health care operations must be consistent with the provider's notice of privacy practices (NPP).  A provider is required to supply the patient with adequate NPP, including the uses or disclosures that the provider may make of the patient's PHI and the patient's rights with respect to that information.[5],[6]


Psychotherapy Notes

An exception to permitted disclosures under HIPAA not requiring patient authorization concerns "psychotherapy notes."  HIPAA specifically defines "psychotherapy notes."  Generally, psychotherapy notes are not taken by a mental health provider during a conversation with the patient and are kept separate from the patient's medical and billing records.  Psychotherapy notes exclude medications, dates and times of treatment, treatment modalities and frequencies, clinical test results, and summary clinical information.  Psychotherapy notes are treated differently from other mental health information because they contain sensitive information and because they are the personal notes of the mental health provider that typically are not required or pertinent for treatment, payment, or health care operations purposes.


HIPAA does not permit the provider to disclose psychotherapy notes without patient authorization, except in situations such as the mandatory reporting of abuse and mandatory "duty to warn" situations.[7],[8]  Under Arizona law, a physician's duty to warn obligation is mandatory when there is an "explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim or victims, and the patient has the apparent intent and ability to carry out such threat."[9],[10]


Laws Relating to Substance Abuse Information

Federal substance abuse confidentiality laws are more stringent and do not allow the sharing of patient records concerning substance abuse treatment or rehabilitation organizations funded by the federal government without consent, with very limited exceptions.[11]  Note: some states have heightened state specific standards when disclosing mental health or substance abuse treatment records to other providers.  As such, should you practice in another state, it is important to be aware of any state specific restrictions prior to disclosing information.  


Under Arizona law, physicians are required to disclose medical records without patient authorization when required by law or when ordered by a court, including subpoenas.  In addition, when required for treatment or diagnosis of the patient, the physician may disclose PHI to other healthcare providers without patient authorization.  Physicians may also disclose PHI to other healthcare providers who previously treated the patient without the patient's authorization.[12] 



Re-disclosure entails sharing/releasing PHI received from another source, such as other healthcare providers.  There are federal and state requirements governing the appropriate re-disclosure of PHI.  Accordingly, health care providers must understand their re-disclosure obligations under all pertinent federal and state laws.  Generally, under HIPAA, with proper patient authorization, a provider may disclose mental health records, including those portions created by another provider.  However, "The Confidentiality of Alcohol and Drug Abuse Treatment Records Regulations" generally prohibit re-disclosure of substance abuse treatment PHI, except under a limited set of circumstances.[13] 

Under Arizona law, the definition of "medical records" requires that physicians disclose all medical records when requested, including those created by other providers.[14]  Remember, however, that the more restrictive of the laws will govern whether re-disclosure is permitted.  Psychiatrists should consult their attorney or risk management professional when deciding whether to release mental health/substance abuse records.



Mental health/substance abuse records are afforded stringent confidentiality protections under both federal and state law.  It is not always evident when disclosure is permitted without prior patient authorization.  Psychiatrists should consult with their attorney or risk management professional when faced with a question of whether disclosure is permitted.

[4] United States Department of Health and Human Services, "Health Information Privacy, Uses and Disclosures for Treatment, Payment and Health Care Operations," (last accessed 6/19/2014).

[5] Id.

[6] For more information on HIPAA Final Rule Highlights, see the AWAC Services, a Member Company of Allied World, risk management newsletter: In Session, Vol. 3, Issue 3 (Summer 2013) for an article on the topic. 

[7] United States Department of Health and Human Services, "HIPAA Privacy Rule and Sharing Information Related to Mental Health," (February 2014). (last accessed 6/19/2014).

[8] Note that some states do not have mandatory duty to warn regulations.  It is important to be aware if you are practicing in a state that has a permissive or no duty to warn.  

[9] A.R.S. 36-517.02

[10] For more information on duty to warn, see the article: "Patient Confidentiality Versus the Duty to Warn," in In Session, Vol. 3, Issue 3 (Summer 2013).

[11] Jost, T., "Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series," The National Academies Press (2006).

[12] A.R.S. §12-2294 and §12-2294.01

[14] A.R.S. § 12-2291(5)

Kirsten Lambert, JD, MSW, LICSW, FASHRM, is Vice President of Risk Management for AWAC Services Company ("AWAC"), a member of Allied World.  Ms. Lambert leads risk management services for professional liability policyholders and specialty programs, specializing in psychiatry.  Ms. Lambert has a background in litigation and clinical social work.
Moira Wertheimer, JD, RN, CPHRM, is an Assistant Vice President of Healthcare Risk Management at AWAC, where she provides consulting and client services to Allied World's insured psychiatrists helping them assess and manage the risks that they encounter.  Ms. Wertheimer has a background in psychiatric nursing and law.
A Resident's View of the APA Annual Meeting
By James Palmer, DO, PGY-3
Maricopa Integrated Health Systems, Inc., Department of Psychiatry

This past May, myself and four other residents as well as one attending physician from Maricopa Integrated Health Systems (MIHS) Department of Psychiatry presented posters at the Annual Meeting of the American Psychiatric Association (APA) in New York City, New York. Resident poster presentations included A Successful Case of Clozapine for Treatment Resistant Schizophrenia: A Case Report by Alicia Cowdrey, MD; Identification of Psychotropic Medications Used to Manage Behavioral Problems in Dementia Patients Admitted to MIHS by Maryam Hazeghazam, MD, PhD, Claire Sollars, MD, and Kit Gesmundo, MD; Are We Maximizing or Minimizing the Treatment of Alcoholism in Active Military by Felicitas Koster, DO; and Up at Night: Is Sleep Disturbance a Symptom or a Separate Disorder in Active Military Service Members by James Palmer, DO. Faculty contributors to the above listed presentations included Esad Boskailo, MD, William James, MD, Gwen Levitt, DO, Jennifer Weller, PhD, and Gilbert Ramos, MA. Their assistance and guidance to this effort was quite helpful and much appreciated. Attending psychiatrist Gwen Levitt, DO, presented Still In Uniform: Mental Health Disorders Among Active Military Service Members Compared to Veterans. She was interviewed by an author from Medscape who reviewed her poster. These presentations provided unique opportunities to interface with many national and international colleagues as well as begin to develop a sense of scope to the opportunities available within APA. Sentiments among residents included expressions, "APA is a highly educational experience and it's nice to be able to network with people from around the world.  We also had a great time exploring NYC!" and "I had a very good experience.  It was very educational and productive." These experiences underscored for us all the importance and opportunity for collaboration and ongoing investigation to further the knowledge and understanding in the field of psychiatry. Presenters appreciated the support of faculty psychiatrists from MIHS who were attending the conference to stop by our posters. Presenters also expressed appreciation to District Medical Group for its financial and administrative support for these endeavors.

Drs. Koster, Levitt, and Palmer

MIHS Poster Presenters from the APA Annual Meeting - New York City
Dr. Cowdrey
Dr. Hazeghzam
Report from the APA Assembly - NYC
By Jehangir B. Bastani, MD, DLFAPA
Arizona APA Assembly Representative

The Assembly of the American Psychiatric Association meets twice a year. The spring meeting precedes the Annual Scientific Meetings held in May. This Assembly meeting was held at the Marriott Marquis and was predominantly a paperless meeting, this shift having begum about five years ago. It also saw the use of electronic voting but there were a couple of occasions when there was a call of voting by strength based on District Branch (DB) members -Arizona has 333 votes. Invariably our Area VII loses out to the East and West Coast that are more populated with psychiatrists. The Assembly met for six hours the first day and a lengthy ten hour the next day. It was marked with presentations by APA Officers as well as various Assembly committee chairs.  Action Papers were introduced and discussed on the second and third day, the meeting adjourning after 12 PM on May 4, 2014.  Most of the District Branches in the Area VII and Area IV (Midwest) had only one Representative to represent their DB as Deputy Representatives were not allowed to vote. DB having members less than 450 members in their DB get one Representative.


The Assembly was called to order by Dr. Mindy Young and the usual housekeeping items were cleared such as quorum, prior minute's approval, recognition of members and guests. A quick outline of what was to be accomplished over the next two days was laid out and the Assembly adjourned to the Reference Committees that heard Action Papers (AP). Each Area nominates one Rep. to the five Reference Committees and the APs, based on their topic, are assigned to Reference Committee. Your Rep. being in Area VII is nominated to the Reference Committee on Governance. The authors discuss their AP before the Reference Committee. The floor of the Reference Committee panel is then opened for interested delegate members to present their views and at the end of the hearing that may last from two hours or longer, depending on contentiousness, of the AP, the Panel then works out a consensus decision. This is reported back to the Assembly floor when the AP brought on the floor for debate.  Six AP were assigned to my Committee, we supported two for the Assembly floor to pass.  

Below are some of the highlights of this busy Assembly meeting:

  • Saul Levin MD; APA Medical Director and CEO presented his priorities and vision for the APA. He was committed to changing the APA where it was not the same body from which members who had dropped out earlier would not recognize it. Increasing membership remains his topmost priority and has hired Jon Fleming to head the Membership Committee. The current membership has increased to 35,000 and outreach is made to Early Career Psychiatrist (ECP), Resident and Fellow Member (RFM) as well as International Members. Based on the Porter Novelli audit done earlier, communication between various departments as well as between APA and the DB were cited as a major organizational drawback. To facilitate communication, a new Organization chart was shared with the Assembly and his plan on hiring a Chief Communications Officer. APA is actively working with subspecialties, allied professional as well as consumer groups to form alliances for legislation for our patients and psychiatry. The recent issue of Conflict of Interest (COI) is being addressed by COI Committee with monthly guidelines on the website. He shared working with the VA in attracting young psychiatrists and their EHR and lastly of Senator Tim Murphy's subcommittee reversing HHS decision to remove psychiatric medication from Medicare Part D "protected formulary" status.
  • Mindy Young MD Speaker of the Assembly shared that ABPN's MOC controversial requirement of Performance Review for candidate's Recertification is optional now and ABPN has become more flexible to work with.
  • Integrated Health Care financing model is evolving for caregiver reimbursement.
  • APA Foundation grant to Dade County Florida has instituted a successful School Education Program to educate teachers and counselors to identify warning signs of mental illness in teenagers in need of help. Another initiative is the Jail Initiative by work with Judges for appropriate psychiatric treatment reducing cost on the community of housing prisoners. The "Right Direction" helps employee re: depression overcome destigmatization and make available information and treatment resources. Website:
  • Treasurer report was encouraging that we have turned the losses of prior year by conservative practices to a small surplus this year. Pension for employees' adjustment has wiped out the surplus. The budget excluded the DSM revenue stream and the sales receipt so far has exceeded expectation by paying off the initial cost of 52 million cost of it bringing it to market. The annual meeting attendance in San Francisco last year was 12,500, reversing the year over year down-trend of the prior 4 years. New York attendance of 14,000 is anticipated to increase. The target remains of building for a reserve of $115 million (cost of 2 years for the APA operation).
  • New APA Clinical Practice Guidelines on Initial Psychiatric Evaluation in any setting was rigorously debated Sunday morning towards the end of the Assembly with most members supporting need for such a document but concern that some chapters in it needed reworking (e.g. assessment of cultural factor). It was not passed by the Assembly
  • Action Papers (AP) presented that did not pass was Industry Sponsored (Support) Symposia at the Annual Meeting and Allowing Deputy Representatives to Vote at the Assembly meeting. Withdrawn was removal of FDA Black Box Warning from by Area VII as more study was required. AP passed were Addressing Psychiatrist shortage since 55% of psychiatrist is over 55 years of age, ABPN 2015 Exam Expectations as confusion on the ABPN re: DSM 5 being used, discontinuation of Patient Satisfaction Survey and Physician Pay, HIPPA and State Restrictions on Duty to warn since HIPPA allows for "serious and immediate" danger, Increasing Buprenorphine Prescribing limits were passed.
  • The Officers elected were: Recorder Dan Anza MD and Speaker Elect Glen Martin MD for the Assembly; for Area VII were Craig Zarling MD (OR) Area Representative and Charles Price MD (NV) for Area Deputy Representative.
Report from ISEN - NYC
By Brian Espinoza, MD

The 24th Annual Meeting of the International Society of ECT & Neurostimulation (ISEN), New York City, NY, 

May 4, 2014


APS Member, Dr. Brian Espinoza, attended the 24th Annual Meeting of ISEN in New York City, immediately preceding the APA Annual Meeting, and reports here the updates on ECT and other neurostimulation therapies from that educational gathering.  Dr. Espinoza welcomes your questions or feedback and can be contacted by e-mail at   


Maintenance ECT:  this is long-term ECT in order to preserve wellness once the patient has undergone the initial ECT series;

  • There is published data on Maintenance ECT being used up to 12 years safely and effectively.
  • One study showed that when Maintenance ECT is stopped that 50% of patients have a depressive relapse within 8 months.

ECT in Parkinson's Disease Depression:  not only does ECT help with the depression commonly associated with this condition, but also the "motor" or movement problems.  The effect is temporary, therefore it looks like a "Maintenance" schedule should be applied to preserve the positive results.

t-DCS (transcranial-Direct Current Stimulation):  this explanation is in bold print for a reason; these are the "alternatives to ECT" that you can purchase over the Internet.  Essentially this is a very low level of electrical current passed thru two pads placed on the head.  Because of such a low level of electricity it was FDA "cleared", but never long-term tested for safety and effectiveness:

  • it appears to work by "priming" neurons to fire at a lower level of stimulation;
  • this "priming" appears to increase connections of neurons when challenged;
  • it does appear to have a "moderate" benefit in depression with a relapse rate of 50% within 3 months;
  • it is still being studied for depression, as well as schizophrenia, substance abuse, stroke, and dementia; and
  • one of the leading International experts, Dr. Colleen Loo, who is currently conducting several studies on t-DCS, recommends against using the on-line version at this time as several factors need to be worked out, including:

         1) individualizing electrical current, 2) placement of electrodes, and 3) timing of treatments.

DBS (Deep Brain Stimulation):  this is an FDA approved treatment for Parkinson's disease, Dystonia's and Obsessive Compulsive Disorder.  It involves a Neurosurgeon placing electrodes into deep brain tissue thru two small holes drilled in the skull.  The Neurologist or Psychiatrist on follow-up visits makes adjustment to the electrodes via remote control to obtain maximum benefit.  Over the past few years, there was excitement about this being a potential treatment for depression as during the surgery the patient was awake, and the Psychiatrist could change the emotional state of the patient from depressed to happy by the remote control:

  • 2 recent studies did not show a beneficial effect on depression; and
  • the current thinking is that research should be done on locating different places in the brain to place the electrodes;  there will be more to follow on this intervention.  
Behavioral Health Highlights From the ADHS Weekly Update:  
Greater Arizona Behavioral Health RFP, New Website for Arnold v. Sarn, Cannabis & Palliative Care for PTSD


The following are behavioral health related items from a recent ADHS Update, reprinted here with the permission of its author, Will Humble, MPH 


Arizona Department of Health Services


To sign-up to receive the behavioral health services blog entries, or to view the latest updates without subscribing, visit:



Behavioral Health Services for 14 Counties Go Out to Bid


Now that we have a new integrated behavioral health care model in Maricopa County, we've set our sights on implementing a similar integrated care model in the rest of the state.  Our Procurement Team issued the Greater Arizona Behavioral Health RFP this week- which sets the course for integrating behavioral health and physical health for folks with a serious mental illness as we select behavioral health authorities in the rest of Arizona.


The Greater Arizona Behavioral Health RFP solicits bids from entities that provide integrated behavioral and physical health for folks with a serious mental illness- much like the Maricopa County contract.  People in the general mental health or substance abuse categories will get behavioral health services from the RBHA and their physical health care from an AHCCCS acute care health plan.


The bid is structured to consolidate several of the current Geographic Service Areas.  When the new contracts go live in October of 2015, we'll have a total of 3 service zones (North, South, & Maricopa)- rather than the current 6.  We've also ensured that tribal land aligns with the service areas.  Of course- tribes wishing to continue as a Tribal Behavioral Health Authority would continue as-is.  The solicitation makes it clear awardees will only be able to hold a contract in 1 service area.  We plan on reviewing the proposals beginning in October and awarding the contracts by the end of the year with an October 1, 2015 start date. 


New Website for Arnold v. Sarn Case


A few months ago the Governor announced a final agreement had been reached in the 32 year old Arnold vs. Sarn case regarding care and services for individuals with serious mental illness. The Settlement is the foundation to end the lawsuit while establishing a blueprint for a successful community-based behavioral health system in Arizona.


The Agreement includes an increase of services in four areas: Assertive Community Treatment, Supported Employment, Supportive Housing and Peer and Family Services.  The Agreement also provides for the use of several tools to evaluate services provided in Maricopa County, including a quality service review, network capacity analysis and SAMHSA Fidelity Tools


This week we launched a new Arnold v. Sarn website  that provides transparency on the review process.  The site will feature details about each of the four SAMHSA Fidelity Tools being implemented along with reports on how we're doing at each.  By early August we plan to have online self-paced video presentations about the evidence-based tools.


Additionally, we hit the ground running with the fidelity reviews process - we added four new team members to our behavioral health team and have trained them over the past couple of weeks to serve in the role of fidelity reviewers.  You can read about them and their role on the site.  Technical assistance sessions for the community are planned and will take place over the next couple of months.  A big thanks to Kelli Donley and our entire behavioral health team for coordinating this evidence-based initiative.


Director's Decision: Cannabis & Palliative Care for PTSD


Last December I denied a petition to add Post Traumatic Stress Disorder (PTSD) to the list of debilitating medical conditions that qualify people for an Arizona Medical Marijuana Registration Card.  I denied the petition because, at the time, I believed there was a lack of scientific evidence to document whether Cannabis is helpful or not to treat or provide palliative care for PTSD. 


The Petitioners appealed my decision to the Arizona Office of Administrative Hearings earlier this year.  A few weeks ago the Administrative Law Judge ruled that: "...  the Appellant's appeal is granted and that PTSD is added to the list of debilitating conditions for which marijuana may be dispensed". 


Among the reasons why Judge Shedden issued a recommendation that was different than my decision was that our Rules invite petitioners to submit information other than peer-reviewed data with their petition...  and I primarily considered the presence or absence of peer-reviewed data in my December decision.  Also, during the March Hearing the Petitioners referred to a manuscript (at the time yet to be published) that found an association between Cannabis use and PTSD symptom reduction in some patients.  That article was subsequently published in the Journal of Psychoactive Drugs (March 2014).  In other words, the information presented by the Petitioners at the Hearing and the subsequent published study provided evidence that marijuana may be helpful in the palliative care of PTSD in some patients. 


This week I issued a Director's Decision that will authorize the use of marijuana (under AMMA) for patients that are currently undergoing conventional treatment for a diagnosis of PTSD.  Physician certifications would be valid only for the palliative care of PTSD symptoms (not treatment).  Certifying physicians will be required to attest that they have reviewed evidence documenting that the patient is currently undergoing conventional treatment for PTSD before signing the medical marijuana certification.


The implementation date of this Decision will be January 1, 2015.  This allows a few months for certifying physicians, dispensary medical directors, and dispensary agents to develop policies and procedures and educational materials required by our Rules.

Report from ArMA House of Delegates 2014
ArMA Logo
Elizabeth A. Kohlhepp, MD, DFAPA
Brian Espinoza, MD
APS Representatives to the ArMA House of Delegates

The Arizona Medical Association House of Delegates and Annual Meeting was held on May 31 to June 1, 2014.  In attendance as Delegates of the Arizona Psychiatric Society were APS members, Dr. Elizabeth Kohlhepp and Dr. Brian Espinoza.  In addition, APS Past President Dr. Gretchen Alexander attended as a current member of the Arizona Medical Association Executive Board and member of the ArMA Public Health Committee. The only resolution presented this year with direct relevance to APS and psychiatry was a resolution pertaining to gun ownership by the mentally ill. That resolution restricting gun ownership by all persons deemed mentally ill has been presented in differing forms in the past several years, and was referred to the Public Health Committee in 2013 and discussed at a meeting of the same held that Fall and attended by Drs. Kohlhepp and Dr. Alexander, together with former Delegate Dr. Michael Stumpf.  The resolution was re-written this year to endorse an action that Arizona statutes already mandate and presented again to the House of Delegates.  In both the meeting of the Public Health Committee and at the ArMA House of Delegates, our Society representatives expressed concerns that the resolution is unnecessary because it is redundant with existing Arizona statutes which require that any patient who is designated DTO (danger to others) be placed on the NICS database so that they may not purchase firearms (or at the very least so that they are flagged in a background check so that legally licensed firearm sellers will not sell to them). 


The 2014 Resolution was again referred back to the Public Health Committee and was not adopted at the House of Delegates.  APS Delegates and Dr. Alexander have been invited to attend a meeting of the Public Health Committee, scheduled to occur this Fall, which will include a discussion of this resolution, and are working with ArMA to coordinate having the sponsoring party present at that meeting to clarify what is currently covered by existing Arizona statutes. 


Dr. Gretchen Alexander was elected as Vice President of the Arizona Medical Association at the House of Delegates.  The Society extends congratulations to Dr. Alexander, with sincere thanks for her hard work and advocacy!  Our thanks as well to Drs. Kohlhepp and Espinoza for their extra contributions in serving as Delegates.  Dr. Espinoza will continue on in a second year term as Delegate in 2015, and Dr. Kohlhepp's second year concluded in 2014.  If you would like the opportunity to serve as the Delegate to the Arizona Medical Association House representing the Society for 2015 and 2016, please contact Teri.

Legislative Report from the 51st Legislature
By Joseph F. Abate, Esq.
Arizona Psychiatric Society Lobbyist

CLICK HERE to view and/or print the Legislative Health Care Legislation Report from  the 51st Legislature, Second Regular Session, 2014.  In this election cycle year, it is important to connect and get to know the candidates that you support and who support the ideals and messages you wish to be conveyed at the State and at the National level.  I encourage all members to attend Town Hall meetings or political fundraisers to get to know your candidates better and to be a part of the process.  During the Legislative Session, I am at the Capitol Complex most days from Monday through Thursday.  If you are ever interested in meeting me there, please call ahead to set-up a mutually convenient time (602-380-8337).  Please stay posted for updates on the Sunrise process and whether or not an Application is made by Psychologists Seeking Prescribing Privileges on or before the September 1, 2014 deadline.  

CME:  2015 Update in Psychiatry Early Bird Ends August 31; California Psychiatric Society; Grand Rounds Resume; eFocus FREE CME

2015 Update on Psychiatry, Continuing a Proud 23-Year Tradition, February 16-19, 2015, J.W. Marriott Starr Pass Resort, Tucson, Arizona, presented by the University of Arizona College of Medicine Department of Psychiatry (Early Bird Rates End August 31, 2014)  

This gem in the desert is a four day accredited course that maintains its strong core in psychopharmacology as it relates to depressive, bipolar, anxiety, and psychotic disorders.  

Additional topics will include evidence-based psychotherapy, the dilemmas of psychiatric diagnosis and dual diagnosis, personality disorders, and much more.

The University of Arizona College of Medicine at the Arizona Health Sciences Center is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Arizona College of Medicine at the Arizona Health Sciences Center designates this live activity for a maximum of 24.25 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity. 

For more information, or to register, please visit:



27TH ANNUAL PREMIER CONFERENCE OF THE CALIFORNIA PSYCHIATRIC ASSOCIATION, September 19-21, 2014 at Tenaya Lodge in Yosemite, California 

Offering an outstanding scientific program and collegial gathering! 
It is western wear and a relaxing atmosphere for a weekend of learning and fun!  For more information or to register online, visit, or you can register just by calling the CPA Office at 800-772-4271.  

Grand Rounds Sponsored by the Department of Psychiatry at Banner Good Samaritan Medical Center Resume in September

Held from 12:00 Noon to 1:00 pm in the Medical Education Amphitheatre at Banner Good Samaritan Medical Center, the Grand Rounds Sponsored by the Department of Psychiatry at Banner Good Samaritan Medical Center resume on September 5, 2014.  Offering a diverse and interested array of topics, for more information, view the Flyer.   


Southwest  Psychoanalytic Society invites you to register to attend 

(CLICK HERE for the full flyer and registration information)  


ADHD: A Neuropsychoanalytic Perspective

Presented by Richard Gottlieb, MD, PsyD

Saturday, September 27, 2014, 9:00 AM to 12:00 PM

Pima County Medical Society, 5199 E. Farness Drive, Tucson, AZ



eFocus:  Understanding the Evidence - Off-Label Use of Atypical Antipsychotics


The APA has developed a FREE CME program about evidence for effectiveness of off-label use of atypical anti-psychotics, with grant support from the Agency for Healthcare Research and Quality (AHRQ).  The goal of the program is to help physicians make informed treatment decisions based on the evidence for off-label use  of these medications.  This interactive CME program is part of a series of 10 multimedia clinical vignettes and a self-assessment test available for CME and self-assessment credit at  

Update from Rwanda:  Walking in Kigali
By Robin Reesal, MD, FAPA

Dr. Robin Reesal, Newsletter Chair of the Society from 2012-2014, is working with his wife, Helen Ewing, RN, DHSc, in Rwanda, and shares with us this observation on Walking in Kigali.  Close your eyes, and you can imagine it well . . .

June 2014


A few times per week I take and enjoyable one hour walk to downtown Kigali from our home in Kacyiru. The hike is up and down hills along paved roads. What is it like?  


The sidewalks are filled with men, women and children. One sees business people in their suits and ties, workers in varied outfits, grade school and high school students dressed in uniforms of various colors, women balancing baskets on their head filled with fruits or vegetable, and men walking with bags of goods on their shoulders. At the side of the streets I pass people sweeping dirt with straw brooms. Others are planting flowers, cleaning gutters, or fixing sidewalks.


Rwanda is a clean country with minimal litter. Kigali and Rwanda in general pays close attention to road side debris and is ecofriendly, as much as possible. Plastic bags can be confiscated at the airport on arrival. One Saturday morning is put aside each month for public service. In many cases citizens will use the time to clean around their house.

Some locals acknowledge ones presence, when we pass along the street, while others do not. In some areas people ask for money.  This mainly comes from the street children who do not have a stable home. One does not see people living in the street in cardboard boxes or pushing supermarket baskets.


Streets are a bustling source of commerce. Street maps and tourist books are popular sale items. Street merchants/agents wearing a bib with their telephone company's logo sell air time for phone companies. Cell phones are the life blood of Rwandans. Texting and phoning is the major means of communication.


At the major corners one sees armed police or military personnel with machineguns. They can be a source of comfort or distress depending on one's perspective. Most will say hello as I pass and extend my greetings. They have been respectful and polite. They stop cars to check driver's license and insurance. Front seat passengers are required to wear seat belts. Motorcycle drivers are required to wear helmets and carry an extra helmet for their passenger.


Sidewalks are more frequent than one might expect. Some are in good condition while others are not. There can be gaps in the cement or large unexpected holes.  There are few signs to warn of impending dangers. Vigilance while walking is a must. When walking, one may get a blast of brown dust and black diesel smoke blown in one's direction from passing cars and trucks. There are fumes from older vehicles to breathe in. One can feel the swish of air as vehicle pass close by. Walk to close to the side walk edge and you could get hit by a passing vehicle mirror. One soon learns that pedestrians have few rights. But, unlike many developing countries there is no smell of garbage or rotting food on the side of the road.


At circle intersections smaller vehicles defer to the larger ones or to the vehicle that is most strategically placed. Flashing of head lights and horn beeping are commonly use to communicate with other drivers and pedestrians. While road safety is emphasized cars are usually racing and dodging other vehicles. Ones sees a preponderance of white and green mini buses filled with passengers. These are used for public transport and priced at a rate that most can afford less than 75 U.S. cents. There is the equivalent of a conductor on each bus who takes the fares and makes sure each seat is filled.


Most cars are small compacts made in Asian.  There are high end cars too, such as Mercedes and Land Rovers. The main roads are crowded at rush hour 6 to 9 am and 4 to 7 pm. The motorcycle taxies provide a steady running high pitch motor noise as they roam the streets searching for customers. Transport trucks of all types lumber up hills with a lineup of cars behind them. The main roads are paved and the side roads in the neighborhoods are usually made of dirt.


Street names are a new addition. Giving a taxi driver a street address in many cases leads to a questioning look. Rwandans have not grown up with street numbers.  Districts and landmarks usually serve to identify a house location. To get home one gives them the name of a land mark then directions. They usually understand simple English phrases.


There are picturesque views of green hills along with the populated valleys. There are colorful plants to see. The neighborhood houses vary in age, level of construction and size. There are houses fit for locals of all incomes and houses for those who want western standards. Some house owners along the walk have vegetable gardens in their yard and this is encouraged.

Along my route there are pockets of stores that serve local neighborhoods. There are usually people standing outside the shops. Customers abound at noon to two pm when businesses stop for a lunch break and in the evenings at the end of work days. There are grocery shops, restaurants, butcher shops, seamstresses, hardware shops, beauty salons, places to pay ones electricity bill and spots to buy office supplies. These areas are community hubs.  


There are parks and multistory office buildings closer to the city center. Construction of new office buildings in the downtown core is prominent. If lost, a look up at the Kigali Tower can help with orientation. It is said that this downtown building is the highest building in Rwanda. The Tower symbolizes the rise of this nations pride and the desire to show others that Kigali will be a world class city one day.


The walks seem safe and enjoyable in the daytime.  Could one walk at night? Yes, but that would depend on the neighborhood just as in any major city.

Compared to other developing countries that I have visited in African and Asia, Kigali seems safer, cleaner and just as enjoyable but vigilance is still a necessity. 

If you would like to subscribe directly to receive all of the updates from "Partnering with Rwanda," visit the BlogSpot by CLICKING HERE.  
Sunshine Act; Fellowship; Respond to Greater Arizona RFP Survey

The deadline to complete a two-phase registration process necessary to review data on payments or other transfers of value from pharmaceutical and medical device companies and dispute any errors with the Centers for Medicare and Medicaid Services (CMS) has been moved out from August 27 to September 8, 2014 due to CMS technical issues and investigation of possible mis-reporting.  The collection and reporting of these data are required under the Physician Payment Sunshine Act, part of the Affordable Care Act.  APA has posted a number of RESOURCES for the use of its members.  Registration is voluntary, but it is required to review the data and dispute any inaccuracies.  While the initial review-and-dispute period ends September 8, identity verification can take some time, so CMS is recommending that registration be completed as soon as possible.  Physicians still have until December 31 to dispute 2013 data, but disputes will not be flagged in the public database until 2015.  If you have not acted yet, do so NOW.  The public website will be available on September 30, 2014.

Are you ready to take the next step in your professional career?  Members who apply for Fellowship and are approved this year will be invited to participate in the Convocation of Fellows during APA's 2015 Annual Meeting in Toronto.  The deadline for U.S. members is September 1st.  For more information and an application, CLICK HERE.  Applying for Distinguished Fellow must be coordinated through and submitted by the District Branch.  That deadline for 2014 is past, but if you would like to apply in 2015, it is never too early to begin the process.  If you would like more information on Distinguished Fellowship, please e-mail Teri (

In a recent e-mail, Society members were invited to provide feedback for the benefit of any requesting bidders for the Greater Arizona Behavioral Health Request for Proposal on what is working well and should be continued; what needs improvement; what gaps in service exist; suggestions for how to address those gaps in service; and your early comments on the integrated care roll-out and suggestions regarding the same.  COMPLETE AND SUBMIT THE SURVEY ON OR BEFORE AUGUST 20, 2014 IN ORDER FOR YOUR COMMENTS TO BE HEARD.