Volume 5, Issue 3                                                                                     Like us on Facebook

APS Newsletter Committee:
Monica Taylor-Desir, MD, MPH, Chair
Gretchen Alexander, MD
Elizabeth Kohlhepp, MD, DFAPA
Register Today for the 2015 Update on Psychiatry!
This four day course in Southern Arizona offers an update of current clinical practices and research focusing on psychopharmacology topics and will help you prepare for Maintenance of Certification by the American Board of Psychiatry and Neurology. CLICK THE ICON ABOVE for the full Agenda and registration options (single day registrations and group registration discounts available).
Fall Social and Why Advocacy Matters in Tucson, clockwise from front:  Drs. Kitzman, Sadr, King, Curry, Thienhaus, Gentile, Chasleen, and Ms. Groppenbacher.

A Fall Hello!

Monica Taylor-Desir, MD, MPH
Newsletter Chair                                    October 2014

Welcome to the advocacy edition of the Arizona Psychiatric Society Newsletter. How many of you think of yourself as an advocate? In the past I would often equate advocacy with politics and say, "I went into medicine so I wouldn't have to deal with politics." The Merriam-Webster definition of an advocate is "one that pleads the cause of that supports or promotes the interests of another. When you think of it that way you could say all doctors are advocates for their patient. Part of the mission statement of the American Psychiatric Association is to, "promote the highest quality care for individuals with mental disorders (including intellectual disabilities and substance use disorders) and their families."
In this issue we will examine the issue of naturopaths expanding their scope of practice.   Dr. Alexander has given us a review of the medical harms of marijuana.  In our community spotlight, The Community Partnership of Southern Arizona shares its 15 year history of work to reduce stigma, raise awareness, and support recovery in the community through their annual art show. Finally, Dr. Reesal has submitted a very thought provoking article to prompt us to think about our ethical response in several clinical scenarios he has developed.
An advocate can come in various forms. You may consider yourself an advocate simply by casting your vote in your professional organizations and in your local, state, and national elections. Many of us will have an opportunity to vote this election on the appropriation of resources for care of the mentally ill. You may consider yourself an advocate by presenting your research or clinical experience in local or national professional annual meetings. If you are presenting at an annual meeting please let us know so that we may highlight your presentation in our newsletter. Whether you consider yourself a quiet advocate or an upfront
political warrior, your
patients and your community benefit from your work and your commitment in providing excellent, ethical, and appropriate health care and in maintaining standards of mental health care. Enjoy the cooler weather in Arizona and consider turning over a new leaf by making a new commitment to advocacy.
Senator Nancy Barto stopped by the Fall Social and "Why Advocacy Matters" event in Phoenix and provided members in attendance with an opportunity for face-to-face conversation on topics important to psychiatry and the provision of behavioral health in our community.  Pictured here, L-R:  Drs. Aaron Wilson, Payam Sadr, Brian Espinoza, Senator Barto, APS Lobbyist Joe Abate, and Dr. John Blount.
President's Message on Advocacy and More
ED Teri and APS President Sadr at the Tucson Fall Event
Payam Sadr, MD, FAPA
President, Arizona Psychiatric Society

I would like to thank all who participated in the Fall Social and "Why Advocacy Matters" events, most specifically our members, the executive officers, our Lobbyist Joseph Abate, Executive Director Teri Harnisch, sponsor representative and presenter Shannon Groppenbacher, and legislative guest Senator Nancy Barto. This advocacy event, sponsored by Johnson & Johnson Health Care Systems, Inc., helped inform all about advocacy as a resource to relate better to our patients and provide maximum quality of care for them, and provided an opportunity for the psychiatric community to become familiar with each other and to have better understanding of how to be active with legislation and legislators.

Recently, APS executive officers had a productive meeting with key leadership of the Arizona Psychological Association (AzPA). AzPA leadership and APS leadership discussed ways to work collaboratively in the provision of emergency psychiatric care, the appropriate psychiatric and psychological care for patients, common educational topics to our members, and mental health first aid education in our community. Dr. Segal (as President-Elect) and I (as President) volunteered to serve on an Inter-Disciplinary Committee in support of these efforts.

Currently there is a Sunrise Application by the Arizona Naturopathic Association asking for more extended prescribing privileges, a measure likely to compromise our patients' safety. The Arizona Medical Association, APS, and Arizona Osteopathic Medical Association, together with their national organizations, are working diligently to assure that all the relevant data is provided to the members of the Committee hearing Sunrise Applications (likely to be scheduled after the November elections). Read more about this in the important article prepared by Dr. Segal. We encourage our members to contact their legislative representatives to encourage opposition to this request for expanded scope of practice on a matter so important to patient safety and care.

As for the advocacy matters, there are themes which would need the members' support to consider: issues such as "suspension v. termination of Medicaid benefits for incarcerated individuals", "mental health parity," and the treatment of the mentally ill within our prison system.

I am grateful for the participation of our community in our common goal of looking to further our provision of care and to bring about better understanding of psychiatric afflictions.

Protect Patient Safety: Act Now to Oppose Naturopath RxP

Roland B. Segal, MD, President-Elect
APA Deputy Assembly Representative
Arizona Psychiatric Society

On September 1, 2014, Arizona Naturopathic Medical Association (AzNMA) submitted a Sunrise Application requesting expansion of their scope of practice to permit naturopathic doctors to prescribe and administer all drugs. AzNMA argues that Approved Naturopathic Medical School adapted pharmacology curriculum, and naturopathic doctors in Arizona are required to complete an additional 60-hour pharmacology course prior to being allowed to prescribe "prescription only" medications. 

In Arizona, naturopathic doctors are already permitted to prescribe most allopathic medications, except four classes: antipsychotics, schedule II controlled substances (except Morphine and Hydrocodone), intravenous, and chemotherapy medications. 

Arizona Psychiatric Society, along with the Arizona Medical Association, and Arizona Osteopathic Medical Association, are opposed to this expansion of prescription privileges. We take this stance because there is a clear difference in fundamental practice of medicine. 

Naturopath's current training and licensure

Naturopathic doctors lack both essential training as it is in traditional allopathic/osteopathic medical schools. Arizona does not require naturopathic doctors to complete internship/residency training. Although naturopathic doctors spent four years in graduate naturopathic schools, the majority of their time is spent studying naturopathic remedies that are clearly different from allopathic high potency medications. 

According to the Association of Accredited Naturopathic Medical Colleges, as of 2014 there are seven naturopathic doctoral medical institutions offering naturopathic doctoral degrees in North America. The Council on Naturopathic Medical Education (CNME) is the accrediting body for these programs. 

Graduates of the CNME accredited institutions are given a degree of Naturopathic Doctor (ND) or Naturopathic Medical Doctor (NMD), and are eligible to sit for the Naturopathic Physician Licensing Examination (NPLEX) that is administered by the North American Board of Naturopathic Examiners (NABNE). Currently, there are 778-boarded naturopathic physicians in the United States. There are 893,851 active physicians (MDs and DOs) in the United States, and 16,281 in Arizona.

According to Naturopathic Physicians website, a licensed naturopathic physician attends a four-year, graduate level naturopathic school and is educated in "all the same basic sciences as an MD, but also studies holistic and nontoxic approaches, clinical nutrition, homeopathic medicine, botanical medicine, psychology, and counseling." Four programs offer one or two-year residency programs for naturopathic doctors, except in the state of Utah, NDs are not required to complete residency training. 

Naturopathic doctors are licensed in 17 jurisdictions within the United States (Alaska, Arizona, Colorado, California, Connecticut, District of Columbia, Hawaii, Kansas, Maine, Minnesota, Montana, New Hampshire, North Dakota, Oregon, Utah, Vermont, and Washington). South Carolina and Tennessee prohibit the practice of naturopathy. The scope of naturopathic medicine varies widely between the other jurisdictions. Thirteen jurisdictions, including Arizona, permit prescription of allopathic medications. Ten jurisdictions, including Arizona, permit minor surgeries. 

According to Association of Accredited Naturopathic Medical Colleges (AANMC), naturopathic medicine follows six principles, holistic, nontoxic approaches, along with an emphasis on disease prevention and optimizing wellness. These principles utilize the most natural, least invasive and least toxic therapies, and to trust in the body's inherent wisdom to heal itself. Some of the modalities that are employed by naturopathic physicians include botanical medicines, vitamins, minerals, acupuncture, enemas, chelation therapy, reflexology, exposure to natural elements, soft tissue manipulation, hydrotherapy, meditation, relaxation, and stress management.
American Naturopathic Medical Association (ANMA) is the largest association of naturopaths in the United States. However, there are local/state naturopathic organizations also. Some of these smaller naturopathic organizations are attempting to expand their prescription privileges to include more allopathic medications in their repertoire. 

ANMA opposes the naturopath's proposed and expansion of naturopathic prescription privileges

ANMA specifically stated that they are convinced that naturopaths should not be allowed to prescribe any allopathic medications because when local naturopathic organizations request allopathic prescription privileges, this is against the premise of vitalistic and holistic principles, and is misleading and confusing to the public. The ANMA stance is that Schools of Naturopathic Medicine do not reach the training level of medical schools relating to scientific basis.
The Washington State Medical Association recently successfully opposed the Washington Association of Naturopathic Physicians prescription privileged expansion. Their argument was that NDs lack sufficient substantive pharmacological and other training to enable them to safely prescribe Schedule II-V controlled substances (namely, testosterone and codeine), and allowing unsafe prescribing practices poses risk to the public.

Consider reaching out to your legislative representative to let them know where you stand on this issue.

Winter Workshops:  January 8, 2014 PM (Phoenix) and January 10, 2014 AM (Tucson)
SAVE THESE DATES for the next offerings in the APA Train-the-Trainer outreach.  Drs. Carol Olson and Edward Gentile will share timely updates related to The Affordable Care Act and health care reform as they relate to your practice.

Risk Management and Liability Issues in the Integrated Care Setting [1]


By Kristen Lambert and Moira Wertheimer of AWAC Services Company, a member of Allied World Assurance Company Holdings, AG ("Allied World")


(This is the second installment in a two-part series from Allied World on risk management issues relating to integrated care.)


The Patient Protection and Affordable Care Act (PPACA) afforded millions of Americans access to physical and mental health care for the first time.  As a result of the increased demand for health care, integrated care or collaborative care models are increasingly being utilized to provide mental and physical health care concurrently to patients. In fact, several studies have shown that the integrated care model has shown to positively impact those with depression.[2]  

Under integrated care models, primary care providers, psychiatrists and other mental health providers offer across-the-board physical and mental health care in consultative and/or collaborative arrangements.  The psychiatrist's liability exposure varies depending upon their role providing care.  This article briefly discusses the psychiatrist's various roles and attendant liability. For a more detailed discussion on liability in the integrated care model, see American Psychiatric Association's "Resource Document on Risk Management and Liability Issues in Integrated Care Models," (Bland, Lambert and Raney, 2014).[3] 


By way of review, when a medical malpractice negligence claim is brought against a physician, the plaintiff alleges that a doctor-patient relationship existed, the doctor owed the patient a duty of care, and that the doctor breached the duty of care, which in turn resulted in harm to the patient.  In order for a duty to be owed to the patient, there must be the existence of a doctor-patient relationship.  


Generally, a doctor-patient relationship is established when the psychiatrist agrees to treat the patient.  However, a doctor-patient relationship may be established under a variety of other circumstances including providing a one-time consultation and/or collaborating with or supervising other providers.  Most often, when a patient asserts a negligence claim, courts and juries will first consider whether such a relationship exists and may look at several factors when making the determination, including[4]:


Whether a contractual relationship between the consulting physician and the facility

providing care required the consultant to provide advice.

  • The degree to which the consultation given affected the course of treatment.
  • The ability and independence of the immediate care provider to implement his or her own decision.[5] 

A psychiatrist considering practicing within an integrated care setting should consult with their local attorney/risk management professional for guidance on their specific practice arrangement prior to treating patients.  There are three roles to consider within this model: consultative, supervisory and collaborative.  Depending upon the setting, a psychiatrist may assume any or all three roles.   




When practicing integrated care, psychiatrists generally provide two types of consultations: formal and informal consultations ("curbside" consultations).  A psychiatrist's liability exposure depends upon the type of consultation performed, the specific circumstances of a case and any applicable rules/case law/regulations in your state.


Characteristics of a formal consultation:

  • Requested by a treating physician in writing or verbally.
  • Results in the creation of a doctor-patient relationship and a legal duty to the patient.
  • May be accomplished through a variety of methods, including face-to-face interviews of the patient, telephone assessments and/or medical record review.
  • Documented in the patient medical record and may include a bill for the consult and/or the consultant may prescribe per the arrangement.[6]

Characteristics of an informal consultation:


Generally occurs when a treating physician seeks the informal advice of a colleague concerning a course of treatment for a patient.

  • Typically does not result in the creation of a doctor-patient relationship.
  • The patient's identity is rarely known to the consultant. 
  • Face-to-face interview/assessment of the patient not typical.
  • Usually is not documented in the patient's medical record.
  • Typically not reimbursed for services.
  • The treating physician remains in charge of the patient's care and treatment.

Supervisory Relationships:


A supervising psychiatrist may not have any direct involvement with the patient.  However, by virtue of his role, they likely retain some level of responsibility for the patient's care.  Key points for the psychiatrist to consider when acting in a supervisory role include: 

  • Generally presents the highest risk of liability for the supervising psychiatrist.
  • Supervising psychiatrist has the ability to alter recommended treatment and direct other providers involved in the patient's care.
  • Supervising psychiatrist is responsible for the actions of their staff (medical and administrative), under the doctrine of Respondeat Superior.[7]
  • Supervising psychiatrist typically "signs off" on progress notes and treatment records, indicating agreement with the care provided.
  • Liability may vary among jurisdictions. 

Collaborative Relationships:


Collaborative relationships may be complicated as the psychiatrist and other care providers share the responsibility for providing patient care and must agree upon the basics of the patient's diagnosis, anticipated therapies and risks that may stem from patient's diagnosis and treatment.


In addition, in collaborative relationships: 

  • Each provider has independent/interdependent duties to conduct ongoing risk assessments. 
  • The psychiatrist may/may not provide direct patient care.
  • There is no supervisory relationship existing between the prescribers.
  • Each provider is responsible for communicating significant changes in the patient/treatment, with all other providers.



As the role of the psychiatrist continues to evolve in integrated care settings, psychiatrists should clarify their role in the provision of care, including any contractual obligations for supervising other providers, providing consultations and communicating patient information.  It is important that you are aware of your ethical obligations as well as state laws regarding the formation of a doctor-patient relationship and providing consultations.  Moreover, be aware when an informal consultation turns into a formal consultation.  Finally, psychiatrists should consult with their risk management professional/attorney for assistance in determining their specific liability exposures.


About the Authors:


Kristen Lambert, JD, MSW, LICSW, FASHRM is Vice President of Risk Management for AWAC Services Company, a member of Allied World Assurance Company Holdings, AG ("Allied World").  Ms. Lambert leads risk management services for professional liability policyholders and specialty programs, specializing in psychiatry.  Ms. Lambert has a background in medical malpractice defense and health law and clinical social work.       

Moira Wertheimer, JD, RN, CPHRM is an Assistant Vice President of Healthcare Risk Management at AWAC Services Company where she provides consultin g and client services to Allied World's insured psychiatrists helping them access and manage the risks that they encounter.  Ms. Wertheimer has a background in law and psychiatric nursing. 


Allied World, through its subsidiaries, is a global provider of innovative property, casualty 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.

[1] This information is provided as a risk management resource and should not be construed as legal, technical or clinical advice.  This information may refer to specific local regulatory or legal issues that may not be relevant to you.   Consult your professional advisors or legal counsel for guidance on issues specific to you.  This material may not be reproduced or distributed without the express, written permission of Allied World Assurance Company Holdings, AG ("Allied World").

[2] Katon, W., M.D., et al, "A Randomized Trial of Collaborative Depression Care in Obstetrics and Gynecology Clinics: Socioeconomic Disadvantage and Treatment Response," The American Journal of Psychiatry, (August 26, 2014); Moran, M., "Shifting to Integrated Care Will Save Health System Huge Sums, Report Finds," Psychiatric News, (May 4, 2014).

[3] Note also, that Ms. Lambert is a contributing author on the text: Integrated Care: Working at the Interface of Primary and Behavioral Health Care, in press (anticipated 9/14), APPI publication, Editor Raney, Lori, M.D. Additional information may be found within.

[4] Bland, D.A., Lambert, K., Raney, L., "Resource Document on Risk Management and

Liability Issues in Integrated Care Models," Am J Psychiatry 2014; 1-7: data supplement,

[5] Diggs v. Arizona Cardiologists, Ltd., 198 Ariz. 198 (App. 2000).

[6] Note: Formal consultations may exist regardless of whether the physician is reimbursed for their services.

[7] Latin term- "let the master answer for the acts of his servant."  In other words, the supervisor may be held liable for those he supervises.

Meet Fellow APS Member: Ankur Bindal, MD, MPH

Dr. Bindal is a highly trained physician who has a unique perspective of having grown up in India and embarking on his career in the US at an early age. He graduated from Government Medical College in Punjab, India and came to US to obtain a Masters in public health program in clinical research. He completed a residency in Psychiatry at University of Mississippi Medical Center, and a Sleep Medicine fellowship at University of Michigan Health System.

He has been awarded the American Society of Clinical Psychopharmacology (ASCP)/National Institute of Mental Health (NIMH)'sClinical Scholars travel award; the prestigious Diversity Leadership Fellowship Award by the American Psychiatric Association (APA), and the Ed Draper Outstanding Senior Resident Award. He has presented extensively at national conferences, represented at Graduate Medical Education (GME) committees during his training and was a pioneer in starting the HEALing fellows program (Health, Engagement, Advocacy and Leadership) in 2010 exploring health care diversity among minority population groups in Jackson, MS. He has served on the National Council of Healthcare System & Financing of APA from 2011-2013.


Dr. Bindal moved to Yuma, AZ in 2013 and practices community psychiatry as a part of his commitment to giving back program, and desire to serve underserved population groups. His mantra of practice emphasizes cultural sensitivity, integrated comprehensive health approach, and incorporation of Sleep Medicine as a tie in with mental health. Dr. Bindal is passionate about mental health, stating, "Mental health is an issue that often goes ignored. By addressing and managing mental health needs, I can help provide hope to many people and families in our community. I believe that by working together, we can truly make a difference, and that difference is a healthy body and a healing mind".


Dr. Bindal loves watching Michigan Wolverines and Dallas Mavericks play with his wife and 1 year old daughter. Dr. Bindal loves to eat and enjoys travelling the world and exploring ethnic food.

Dr. Bindal could be reached at

Medical Harms of Marijuana (Information Paper)
Gretchen B. Alexander, MD, Past President, Arizona Psychiatric Society
Vice President, Arizona Medical Association

In recent years, well-organized advocacy efforts have led to significant marijuana policy changes in the U.S. Twenty-three states and the District of Columbia now have statutes which legalize the use of marijuana for medical purposes, and at this time, three states have pending legislation to do so. Furthermore, two states have legalized and a number of states have decriminalized the recreational use of marijuana. 
As a result of these changes, and as a result of effective dissemination of information regarding potential therapeutic effects of specific compounds found in marijuana, there is a growing public perception that the use of marijuana is not harmful. The Arizona Psychiatric Society notes with concern that in some cases, this belief can lead to risky use of marijuana, particularly by young people. It is important to note that in recent years, a growing body of research suggests that marijuana use is not benign. In fact, there is evidence that in the following areas, the potential for substantial harm exists.

1.   Psychosis: ( loss of contact with reality in which the individual experiences paranoia, delusional beliefs, auditory and visual hallucinations): there is a well-documented connection between marijuana use and psychosis. Specific research findings include the following:
* Cannabis use is an independent risk factor for psychosis and possibly schizophrenia, a brain disorder which causes psychosis and disability. People who use marijuana appear to be 1.5-3 times more likely to develop psychosis than people who don't use.
* The more frequent the use, the higher the risk. One study found that daily users of marijuana were at 7 x the risk for psychosis that non-users were.
* People who begin using marijuana as teenagers are at greater risk for developing psychosis than those who begin using as adults.
* People who are genetically vulnerable to schizophrenia appear to develop schizophrenia 2-3 years earlier if they use marijuana.
* Patients with schizophrenia who use marijuana have a worse prognosis for their illness: they are more likely to have severe symptoms, more frequent relapses and to need to stay in the hospital longer when they are sick.

2.   Addiction: contrary to popular belief, it is not only possible to become addicted to marijuana, it is not that uncommon, especially in adolescents:
* One out of every six adolescents (or 17%) who use marijuana develop some combination of tolerance (needing larger amounts to produce the same "high"), withdrawal (physical and emotional discomfort associated with stopping use), and continued use in spite of adverse consequences-also known as addiction.
* 9% of all marijuana users of any age become addicted.
* For daily users, it is estimated that the risk for addiction is somewhere between 25-50%.

3. Cognitive effects:  marijuana use results in poorer attention and concentration, slower and less correct decision-making, and impaired short-term memory. Traditionally, it was thought that these effects were not permanent. However, recent studies using more sophisticated brain scanning techniques and more precise collection of data about marijuana use have found the following:
* Loss of IQ points associated with use of marijuana in adolescence, even if the person quit using as an adult.
* Lower levels of connections between brain areas responsible for learning and memory in marijuana users who began using as teenagers.
* Cognitive effects appear to be related to how much marijuana is used and how early use begins.

4. Driving:   because it is difficult to measure levels of the active ingredient of marijuana in the bloodstream, and because people tend to drive more slowly when they are affected by marijuana, it has been historically considered that marijuana does not affect driver safety. However, a recent review of relevant studies suggests that:
* Risk for involvement in a car accident doubles after marijuana is used.
* Combining marijuana with alcohol worsens driving ability.

5. Respiratory:
  marijuana advocates have suggested that smoking marijuana is less harmful than smoking tobacco because THC, the active ingredient in cannabis, has an anti-inflammatory effect and protects the lungs from toxins. However, there is evidence that:
* Regular marijuana smokers have double the risk for lung cancer.
* Regular marijuana smoking is associated with bronchitis, wheezing and shortness of breath.
* Studies that have found marijuana to have no effects on lung function were done using subjects who were only smoking one joint per week.

6. Pregnancy: there is mixed evidence in this area but recent research findings include the following:
* There is a consistent association between regular marijuana use in pregnancy and neurodevelopmental issues such as attention deficit disorder in the child.
* Some studies have shown an association between regular prenatal exposure to cannabis, and lower academic performance as well as delinquent behavior when the child is 14. The risk for delinquency is 1 and three-quarters the risk for a child of a non-marijuana using mother.

The Arizona Psychiatric Society currently does not have an official position with regard to the legalization of either medical or recreational use of marijuana. However, we believe that it is important for anyone using this substance to be fully aware of the latest information about potential risks and benefits of use. We hope to be able to contribute to a balanced public awareness of information on this issue.  CLICK HERE FOR A PRINTABLE PDF OF THIS DOCUMENT TO USE AS A COMMUNITY RESOURCE.  
Arizona Presentation at IPS--Medical Marijuana in Arizona: Experiences in the Public Health System

Are you attending the 2014 Institute on Psychiatric Services in San Francisco, California.  Plan to att end the following Workshop presented by Arizona peers:  Gretchen Alexander, MD, Aaron Riley, MD, Shabnam Sood, MD, Devna Rastogi, MD, and Nancy Van Der Veer, PsyD:

Medical Marijuana in Arizona:  Experiences in the Public Health System

Sunday, November 2nd, 2014

8:00AM -9:30AM

Pacific Suite B, Fourth Floor

Workshop Abstract:
Marijuana has historically enjoyed a reputation as a psychoactive substance with a favorable harms profile. In spite of substantial evidence that a connection exists between marijuana use and the onset of psychosis, the belief that marijuana is an entirely benign substance remains quite common.

In 2010, the Arizona State Legislature passed legislation allowing the use of marijuana for the medical treatment of specified conditions. The medical marijuana program subsequently created by the Arizona Department of Health Services was intended to ensure access to medicinal marijuana for qualified conditions while minimizing the risk that the program would promote the recreational use of marijuana.

Although the Arizona program is still fairly new, our treatment of a series of patients with psychosis and medical marijuana cards over the last year has suggested that availability of medical marijuana may pose certain challenges in the treatment of the severely mentally ill.

In this workshop we will review the evidence for both therapeutic and adverse effects of marijuana using interactive clinical vignettes, and will discuss specific aspects of the Arizona program which may be interesting to clinicians practicing in states preparing to adopt medical marijuana laws. There will be a breakout into small facilitated discussion groups to share information about clinical cases and as well as experiences with medical marijuana programs in participants' own states.
Collegial Events:  11/1 Residents Fall Mixer; 11/3 First Mondays Kaffe Klatch
Arizona Resident/Fellow Members:  Don't Miss the Fall Mixer this Saturday, November 1st!  Drop in as your schedule permits between 5 and 7 pm at The Vig Uptown (16th Street, North of Bethany Home, Phoenix).  Contact your RFM Representative (Dr. Koster at MIHS, Dr. Goldenberg at Banner, and Dr. Chhatwal at the University of Arizona, or Teri ( with any questions.  
FIRST MONDAYS:  7 PM ON MONDAY, NOVEMBER 3, 2014.  The Door is Always Open at the Home of Dr. Martin Kassel on the First Monday of each Month (beginning at 7 PM).  ALL practice years are welcome--come enjoy an evening of being elbow-to-elbow with your psychiatrist peers.  Refreshments are provided.  Your presence is all that is required to attend!  There is often a discussion starter, but this is an evening geared towards collegial connection, so other topics are welcome.  For the address or any other questions, contact an RFM Representative (above) or Teri (  
The CPSA Community Mental Health Arts Show:  15 Years of Reducing Stigma & Supporting Recovery
Viewing the art from the 15th CPSA Community Mental Health Arts Show

The CPSA Community Mental Health Arts Show is celebrating 15 years of reducing stigma, raising awareness and supporting recovery. Community Partnership of Southern Arizona (CPSA) has sponsored the long-standing event, showcasing the artistic expressions of individuals challenged by mental illness. 

Art is recognized for its therapeutic qualities, which can reduce the intensity of symptoms, increase confidence, and play a role in on-going recovery. The variety of artistic media included in the arts show is more than a joy for the eyes, providing a platform to articulate and express emotions. Awareness is also a poignant dynamic of the arts show, revealing the talents, triumphs and experiences of youth, adults and families coping with mental illness. The event was created to meet a community need for behavioral health outreach and public education. Community stakeholders came together to answer the call and established the Community Mental Health Arts Show. 
In July 1995, CPSA became the Regional Behavioral Health Authority (RBHA) contracted by the Arizona Department of Health Services Division of Behavioral Health Services to coordinate and manage publicly funded behavioral health services in Pima County. CPSA's core mission is to provide high quality behavioral health services that are member and family driven, recovery oriented, respectful of cultural differences, and foster hope and self-determination. 

In 1998, at the request of community members, The Long Range Public Education Coalition (also known as "The Long Rangers") was formed, with resources provided by CPSA administrative funds. The focus of this committee was to develop and implement a plan of public education to bring about positive change for persons with behavioral health disorders. Long Rangers are consumers, family members, advocates, professionals and others from all areas of the behavioral health field who volunteer their services to the coalition. The group served as the historical foundation of CPSA's community outreach efforts.

In honor of Mental Illness Awareness Week, and as part of their commitment to bring about positive change for persons with mental health and substance abuse disorders, CPSA launched the Community Mental Health Arts Show. 
Artist Ms. Lopez-Santiago

The annual event has achieved great success throughout its 15 year tenure, with attendance and community interest growing on a continual basis. The art displays are a meaningful way of reducing the conventional stigma surrounding mental illness. Community members appreciate the creative capacity and faculties of the artists, facilitating empathy and understanding. 

In addition, many of the participants have shared that art is therapeutic and beneficial. Natalia Lopez-Santiago, an arts show awardee, explained how art has been part of her recovery. "I do think art has been a positive outlet for me. I have a lot of things inside of me that I can't quite get out in words, and I use my art to get it out." 

The CPSA network provides a wide spectrum of support services and evidence-based treatments, including art therapies. The arts show taps into the benefits of art therapy, providing a means of expressing thoughts, feelings, and emotions that may otherwise be difficult to verbalize.
Dr. Edward Gentile has served as the Chief Medical Officer at CPSA for nearly 20 years, and strongly believes in the value of the Mental Health Arts Show, "This a perfect venue for people to share the story of their recovery journey, and a very effective way to communicate that recovery is indeed possible."

The efficacy and impact of the arts show can best be summarized by CPSA President and CEO Neal Cash. "The Community Mental Health Arts Show supports recovery and promotes a better understanding of behavioral health challenges." 

The CPSA Community Mental Health Arts Show features the work of persons with a mental health and/or substance use disorders, and those who work in the behavioral health field. Entry categories include painting, poetry, creative writing, photography, ceramics, drawings and crafts.
There are four award categories, and each year it is a challenge to choose from the exceptional artwork. The awardees of the 15th Annual CPSA Community Behavioral Arts Show are:

Artist Ms. McDaniel
Natalia Lopez-Santiago - The Art of Recovery
Marcia McDaniel - The Best of Show
David Van Sice - The People's Choice and The Arts Show Poster

A short video about the artists, highlighting the role of art in their recovery process, will be available soon. Look for CPSA on Facebook, LinkedIn or Twitter to see the final video when it's released.

CPSA sincerely thanks all participants who submitted entries this year, and looks forward to being part of the journey.

Educational Events
Grand Rounds for the Department of Psychiatry of Banner Good Samaritan Medical Center are held most Fridays, Noon to 1:00 pm, in the 
Medical Education Amphitheater (unless otherwise indicated).  The October 31, 2014 presentation is on Addiction Medicine and Psychiatry: A Comprehensive Revnew, Steven C. Boles, DO, FASM.  November will feature a presentation on each Friday, with the exception of Friday, November 28, 2014.  For the full November Agenda, CLICK HERE.  

The Mind & the Law, A Series of Seven Public Lectures at the University of Arizona: final three lectures will be held Wednesday, November 5, November 19, and December 3, at 7 pm, Ares Auditorium, James E. Rogers College of Law, 1201 E. Speedway, Tucson.  FREE CLE credits available.  For more information on the nationally know scholars and topics, visit  

SOUTHWEST PSYCHOANALYTIC SOCIETY PRESENTS:  Eli W. Lane Memorial Master Workshop, Mentalizing in Treatment Attachment Trauma, Jon G. Allen, PhD, November 1, 2014, 9 am to 4 pm (CLICK HERE FOR FLYER), and Mentalization-Based Treatment Follow-Up to Jon Allen Event, December 6, 2014, 9 am to 12 Noon (CLICK FOR FLYER)

January 9, 2015 - Mayo Clinic Education Center, Phoenix, Arizona
One day workshop co-led by John G. Gunderson, MD, Professor of Psychiatry at Harvard Medical School and Director of the Center for the Treatment of Borderline Personality Disorder at McLean Hospital and Brian A. Palmer, MD, Assistant Professor of Psychiatry, Mayo Clinic.  
Report from the Area VII Assembly - August 2014

APA BenRoland B. Segal, MD, 
President-Elect and APA Deputy Assembly Representative, attended the Area VII Assembly Meeting in Bozeman, Montana in August 2014.  Following is his Report from that Area VII Assembly meeting:  

The APA is focusing on two priorities: Advocacy and Foundation.  The idea of Advocacy is to get to "grass roots" (i.e. each APA member) and get them involved in advocating legislatively for what is important to them.  APA wants to be member driven and aims to represent "the clinicians."  Therefore the effort is to increase member recruitment and retention (i.e. Foundation).  As a vehicle to reach out to the APA members, Area Representatives and Deputy Area Representatives are encouraged to reach out to their members.


Other goals of the American Psychiatric Association is to

  • Promote the rights and best interest of patients and those making use of psychiatric services
  • Improve access and quality of psychiatric services, to
  • Improve research in all aspects of mental illness
  • Improve psychiatric training and education
  • Improve conditions for practice and career satisfaction
  • Foster collaboration among all concerned with mental illness
  • Improve the functioning of the APA in service to its goals


APA Government Relations are focusing on telehealth, integrated medicine, medical marijuana, psychology prescribing, involuntary treatment and mental health parity. 


Dr. Barbara Schneidman presented on ABPN MOC (American Board of Psychiatry and Neurology Maintenance of Certification).  There was much discussion about the new requirements. Some representatives expressed concern over the cost of materials and the recertification examination.  Others brought up concern that the new requirements are strict and some psychiatrist might lose their livelihood by not being able to meet the requirements.


A great deal of time during the meeting was spent discussing the APA Practice Guidelines that will be presented and discussed during the next assembly meeting in November 2014.


I had a great pleasure of meeting the representatives from Hawaii, Idaho, Nevada, Oregon, New Mexico, Washington, Montana, Colorado and West Canada.  In general, all District Branches are concentrating on membership, education and advocacy.  

Ethics Questions and Thoughts:  Crossing Borders
Robin T. Reesal MD DABPN FRCP 
Psychiatrist, Rwanda
Photograph by Dr. Reesal from Democratic Republic of the Congo

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 these reflections on the ethical considerations of providing care across borders.   

While travelling or living in resource poor countries, one encounters stressful situations and ethical dilemmas. This article reviews some of the difficult scenarios one can experience abroad. A few words first about stress and ethics to provide a foundation for the discussion.
Stress, anxiety and depression have multiple origins according to our psychiatric lexicon. Theories and approaches abound on these topics. Behaviorist say an external stimulus leads to a fight or flight response. In psychodynamic terms, a conflict between id and superego causes emotional upset. The cognitive therapist think cognitive distortions precipitate dissatisfaction. Those espousing to the interpersonal therapy view believe poorly managed interpersonal issues cause unhappiness and anxiety. Regardless of one's outlook, people experience stress and know what it is. 

One can use biomedical ethics principles as a guide to interpret and contemplate the life situations one sees when working in resource poor countries. Modern biomedical ethics touches on principles of autonomy, non-maleficence, beneficence and justice. The simplified meaning of these terms are, self-determination, do no harm, helping others and fairness. 

As we go through each situation, consider how your value system, religious beliefs, cultural background and desire to help, influence your ethics. How does your school of thought influence your interpretation of the situations and solutions? 
Scenario 1. As you walk along a street, an 8-year-old child dressed in a school uniform, walking with three other class mates, stops you and says, "give me money"! What should you do? Does your decision-making process change if this happens daily, with different children? How do the children who are not asking for money manage? Does giving money act as a positive reinforcer for other children to do the same? (helping others vs. fairness)

Scenario 2. You are working in an emergency room of an acute care hospital and a 2-year-old child is brought to the emergency room with nausea and vomiting. This appears to be a straightforward case. Take a history, do a physical exam, order labs and give intravenous fluids. You find out there are no available intravenous fluids and you watch the child die. You see this situation repetitively. The staff show very little emotion with these deaths. Why? What should you do? Complain? Give money? How do you manage seeing what you think are preventable deaths? (self-determination vs. helping others) 

Scenario 3. Your living situation dictates that you have house staff who clean and make meals. You are appalled by their low wages. Should you pay them more money? If you decide to do this, what happens when your visit ends and they do not have someone else to cover this gap? (do no harm vs. helping others)

Scenario 4. You are a guest health care worker in a mobile clinic. A 5-year girl comes to the clinic with her 8-year-old brother. The physical exam and history leads to a diagnosis of otitis media. Acetaminophen and an antibiotic are indicated. The clinic has the medications for the child but the parents cannot be reached. There are no other resources to treat the child once the clinic leaves. The clinic gives the drugs to the older child with instructions. What do you think? Were the instructions understood? Will the medications be sold by the parents? Who will help the child take the medication? What other options were there? Would you have given the medication to the children? (do no harm vs. helping others)

Scenario 5. You are brought to a meeting where boys play a soccer game for visitors. After the game you are told, the boys need money for their education and a donation is requested. Their story sounds true. You notice there are no girls in the group. Upon asking, you are told they are at home helping their mothers. Should you give money? What of the young women who are at home and cannot ask for funds? Does giving the money support a system that excludes women? (helping others vs. fairness) 

Scenario 6. You are shown a psychiatric hospital, which represents the country's highest level of care. They are proud of their hospital. While you walk through the hospital, you see patients who are in cinderblock built cells chained to the wall. Is their practice unethical? If so by whose criteria? Should you say something to your hosts? (autonomy vs. fairness)

The above situations are hybrids of circumstances that others and I have experienced away from home. I am not referring to any particular country. I am not sure of the "right" answer and in most cases; there is no "right" answer. However, these situations are examples of some of the non-physical stressors encountered when doing international health care work.
As you formulate your thoughts about these scenarios and make judgments, remember our own history, the Tuskegee Syphilis Study (1932-1972) from which the Belmont report emerged.
My private psychiatric practice in Rwanda is, in main part, about helping expats. Unfortunately, while we send our people abroad there is a dearth of support for them. I describe my job as helping the helpers.

Beauchamp, TL. and Childress, JF.(1994). Principles of Biomedical Ethics, 4th ed. New York: Oxford University Press
Belmont Report: accessed October 15, 2014