Like us on Facebook  Follow us on Twitter                                                                     Volume 5, Issue 4
Monica J. Taylor-Desir, MD, MPH, FAPA
Gretchen Alexander, MD
Elizabeth Kohlhepp, MD, DLFAPA

Sunny, Snowy Day Outside McNary, AZ
Happy Holidays!

Monica J. Taylor-Desir, MD, MPH, FAPA
Newsletter Editor                              
December 2014

I hope that you are embracing the opportunity to share peace and joy with family, colleagues and loved ones and that you will time for rest and rejuvenation as we enter 2015.  Psychiatry is one of the very few fields of medicine that examines the whole person and the environment and culture in which the person maintains their health.  The awareness of a person's culture enriches not only their medical treatment but often I have found the awareness of a patient's culture also enriches the provider. 



Dr. Taylor-Desir

issue of the Newsletter takes a look at the cultural diversity of patients we serve in the State of Arizona.  Arizona Psychiatric Society Member, 

Dr. Mohamed Ramadan, challenges us to make a paradigm shift in the culture of psychiatry by investing in preventive mental health care.  Diana Yazzie Devine, the President and CEO of Native American Connections, has written an article delineating the organization's history and service to the Native American community in the Phoenix area.  Dr. Sandra Combs and Dr. Amelia Villagomez from the University of Arizona share a very thoughtful article on providing psychiatric care to Latino Community.  Finally, from his global perspective, Dr. Robin Reesal writes from Rwanda on the topic of Global Health and Cross Cultural Psychiatry.  This is a great lead in to remind you of our Annual Meeting on April 18, 2015. The theme this year is Preventive Psychiatry: The Benefits of Early Intervention.   Have a wonderful holiday.

MIHS Residents Reach 100% Club Silver Level
We celebrate the Program and resident leadership of the MIHS psychiatry residency program and their support of advocating for the profession of psychiatry.  In the 2014 membership year, 90% of the residents in the MIHS psychiatric residency program renewed or became new members of the APA and APS.  
(L-R) Top Row: Drs. Palmer, Gesmundo, Weinhold, Darling, Barket, Mosley, Chaffin, Figueroa, and Neff; Bottom Row:  Drs. Salmon, Placido, Kim, Marsh, James (Program Director), Koster, Fisher, Cowdrey, and Amani
Sierra Tucson, located at the base of the Catalina Mountains in Tucson, Arizona, is Seeking a Full-Time Psychiatrist
Internationally renowned for its effective therapies, extraordinary staff, and exceptional setting, Sierra Tucson provides integrated treatment to identify and resolve underlying issues. This supportive path has led to recovery for tens of thousands of people who have suffered from alcoholism, drug addiction, depression, anxiety, trauma, eating disorders, chronic pain, and other disorders.  CONTACT:  Sierra Tucson, 
Human Resources Department, 39580 S. Lago del Oro Parkway, Tucson, Arizona 85739, Fax: 520-818-5889, email: (Full-Time Psychiatrist in Reference Line)
President's Message: Naturopaths Withdrawn, Parity, Annual Meeting, and More

Payam Sadr, MD, FAPA

President, Arizona Psychiatric Society


The holidays are a time for reflection and renewal.  I hope they bring each of you time to celebrate with your family and friends the passage of another year and the ringing in of a new one.  Reflecting on the year of 2014, it is my pleasure to inform you that thanks to the collaborative efforts of Arizona physician groups, led primarily by the Arizona Medical Association, and including our Society and the APS Lobbyist, the Sunrise Application by Arizona naturopaths seeking Schedule II prescribing privileges was withdrawn prior to the December 17, 2014 Sunrise Hearing date, as was the Sunrise Application by pharmacists seeking the authority to administer vaccines to children ages six to seventeen.  As scope of practice issues and other legislative proposals with the potential to adversely affect patient care, patient safety, or practice opportunities arise almost every year, we thank you for being members of the APA and APS and for valuing professional advocacy.  On an individual basis, as we had the chance to discuss at our Fall social and advocacy event, it is also important for physicians to continue to maintain personal relationships with key health care legislators and your home or work area legislators.  From January 1, 2015 to the first day of the legislative session (January 12, 2015) is an important fundraising window for most Arizona legislators.  Please consider reaching out and/or attending these events to promote issues advancing psychiatry and patient care.  


To help patients feel empowered to advocate for their own care, in partnership with the Society (and other district branches), the APA has developed an information poster on fair insurance coverage and seeking mental health parity under the law.  Visit the article in this Newsletter for more information and for a downloadable poster/flyer.


Looking forward to 2015, I hope you have saved April 18, 2015, the date for the APS Annual Scientific Meeting, to be held at the Scottsdale Resort and Conference Center.  Our topic is "Preventive Psychiatry: Benefits of Early Intervention," and we are excited about the diverse line-up of top quality speakers. CLICK HERE  to view the current Agenda (subject to finalization).  Look for sign-up information in early 2015 and check the Society website at for updated information. 


Consider celebrating the career achievement of a worthy peer by nominating him or her for the Career Achievement in Psychiatry Award.  CLICK HERE for the award criteria and nomination form.  And I hope you will plan to join us at a special evening to celebrate award winners and socialize together as a Society on Friday, April 17, 2015 (the evening before the Annual Meeting).  The Annual Meeting brochure mailing will contain complete information. 


In closing, the Society celebrates the psychiatric residents from Maricopa Integrated Health Systems-who have together achieved a Silver Level of the APA 100% Club, meaning 90% of the psychiatric residents from MIHS are currently members of the APA and APS.  It is exciting to see resident-fellow members being proactive about their professional career and their patients.  Congratulations to MIHS and thanks to Dr. Felicitas Koster for her leadership and support in achieving this honor. 


Happy Holidays and wishing you a healthy and prosperous New Year!

Click Above for More Information
Makers and Takers:  A New Progressive Look

Mohamed Ramadan, MD, MS, FAPA
Medical Director, Mohave Mental
  Health Clinic
President, Neuropsychiatry Clinic and
  Research Center

Working in northern Arizona for the last 10 years has been an exciting and a very rewarding experience. In Mohave County, we cover the western border of Arizona with Nevada and California and provide psychiatric services for over 250,000. The challenge is how can we provide services to our patients with the resources and the providers shortage that is not limited to Mohave County or Arizona. This is a national and global challenge. 


Mental illness costs the USA $444 Billion each year for treatment, disability benefits, and lost earnings. At any given time, 108,000 hospital beds are occupied by patients with serious mental illness. More than that amount, 590,000 end up in alternative institutions- jails, city streets, and homeless shelters. What is even more shocking is that 40% of adults with severe mental illness such as schizophrenia and bipolar disorder received no treatment in the last year. States have been reducing hospital beds for decades because of tight budgets and during the recession states were forced to make the most devastating cuts in recent memory. States cut 5 billion dollars in mental health services since 2009 and nearly 10% of total psychiatric beds. So the $444 billion question is what to do?


I think the system and mental health have been working hard and spending the most at the end of the mental health spectrum as if we are aggressively treating patients with cancer only if they are at stage 4 or terminally ill.  As we all know, medicine has been recently adding resources for early detection and treating when the patient is still healthier and younger and mental health is no different. Patients with serious mental illness take from the existing resources and require more care.  For example, a single hospitalization OR incarceration may cost an average of $30,000, while a patient living at home may cost the system an average of $30,000 with all services included.


Many patients with serious mental illness most likely are going to take more services and resources in comparison to patients with mental illness who were treated aggressively early on and were able to preserve their ability to function, live independently, work and pay taxes. They are makers and less dependent on our services and limited resources.


What we are doing now is working hard and providing most of the services to our patients later, after so many relapses that may lead to loss of educational opportunities, employment chances, and relationships.  We see patients with criminal records and very challenging employment history, and we hope that we can put their life back together and achieve goals that the patients had for themselves years ago--before their first episode of mental illness. We are asking for a time machine to go back and start all over again after years of suffering.


We can have more makers and less takers if we invest up front in preventive mental health, education about mental health, and early detection at schools and colleges. We can do more to provide training to primary care providers, to screen, treat early, and refer to psychiatrists. We can open access to medications and psychotherapy in early stages of the illness to do everything we can to prevent relapses. We can work with teachers, school counselors and/or social workers, and college counselors to help patients with mental illness finish their school work and graduate.  We can work with the jails to keep patients on their medications and coordinate care with their outpatient providers.


We need to follow the lead of most of medical disciplines going after the illness right after the diagnosis to reach full remission if possible and keep our patients healthy and still able to contribute to their full potential.


We can also do more to support patients' caregivers and families to provide them with resources and services they need to keep the patients at home and to minimize the risk for relapse and the need for hospitalizations or Emergency Room visits.


I have a dream that patients with mental illness will get the attention and treatment plan that patients with any medical chronic illness are able to get, and we will all see more of our patients living a full, productive life.


We need ideas and a vision to reach out to our patients when they need us the most and when they have all their life ahead of them and so very much to lose.

Private Practice Office Space Available in Tucson
Private practice office space available in Tucson Medical Park across from Tucson Medical Center. Share overhead with two other psychiatrists, a psychologist, and a masters level therapist.
Contact:  Shari at 520-795-0309.  
Spotlight on Cultural Diversity:  Native American Connections

By:  Diana Yazzie Devine
        President/CEO Native American Connections

Diana "Dede" Yazzie Devine, Native American Connections President/CEO has been working with Native American urban and tribal entities since 1972 and has been employed as the CEO of Native American Connections (NAC) since 1979. NAC is a 501(c)(3) Native American operated nonprofit corporation that provides comprehensive behavioral health services, affordable housing, and community based economic development opportunities. NAC serves all populations with a targeted mission to serve Native Americans living both in the Phoenix urban area and from tribal communities. NAC offers innovative research-based behavioral health counseling and substance abuse treatment that is integrated with Native cultural and traditional healing practices.

Native American Connections (NAC) was founded in 1972 to provide a safe, supportive place for Native American people to live who were coming to the Phoenix metropolitan area seeking jobs, educational opportunities, and escaping overcrowded and substandard housing/living conditions on tribal reservations.  The NAC founders were recovering alcoholics themselves who were committed to providing an environment that supported recovery, healing, and individual, family and community wellness.


I began working for Native American Connections in 1979 when NAC services consisted of only one single program, Indian Rehabilitation (IR), providing residential alcohol and drug treatment and recovery services for Native American men.    Indian Rehabilitation was and still is a 16-bed residential, Arizona licensed, recovery center located in the heart of downtown Phoenix.  IR was first licensed by the Arizona Department of Health (ADHS) Office of Behavioral Health Licensure (OBHL) in 1978 and has license #004 which is now the oldest license issued in Arizona. 


In 1978, the average IR client was age 44 and alcohol was the drug of choice.  And, even though the Indian population at the time had a much higher rate of abstinence than the general US population, those who did drink had a 450% higher incidence of alcoholism and abuse than the general population.   This translated into Indian people having the shortest life span of all populations, and some of the highest incidences of tuberculosis, diabetes, obesity, unintentional accidents with serious bodily injury, and suicide rates.    Therefore, it made sense for Native American programs like NAC to practice holistic healing and integrated alcohol and drug recovery that supported spiritual and physical healing.  Strong partnerships, co-location and shared staff developed among NAC, Phoenix Indian Medical Center, Native Health and the Phoenix Indian Center looking at the "whole" person needs was common practice for NAC long before the medical and behavioral health professions began promoting integration.  Almost 40 years later, the profile of the average IR client is age 27 with co-occurring illness and poly-substance addiction including prescription drug abuse. 


At the onset, NAC had only three employees and today Native American Connections employs more than 130 people across 15 services sites serving more than 10,000 people annually.  However, the treatment philosophy and Mission remains very much the same - Healthy Mind, Healthy Body, and Healthy Spirit supported by a Healthy Community.   In the beginning, NAC relied heavily on the AA 12-step program and our recovering employees (peers), but was always grounded in the traditional healing practices of the tribal members and communities we serve.  The traditional Talking Circle became the standard practice for group sessions promoting respect, listening, and non-judgmental support rather than confrontational methods.   In 1980, NAC built its first sweat lodge and began providing sweat lodge ceremonies in downtown Phoenix - one for Native men, one for women, and one that is open to the community.   From the beginning, NAC always recognized the historical traumas facing Native peoples and found the traditional healing and purification practices, including the Talking Circle, smudging, drumming and the sweat lodge, to be the anchor practices for long term recovery.   


Cradle Board

NAC's first employees were peers and family members, not because it was clinically sound but because they had a passion and understanding of recovery.   Today, about 25% of our employees are peers, and NAC has purposefully created a pathway for our clients to enter into the field of behavioral health and move though the organization into professional and decision making positions.   And today, NAC serves ALL populations from a healing cultural perspective with Native people remaining our target population.   About 60% of the people we serve are enrolled tribal members from communities throughout the Southwest. 


Because NAC has always listened to the "user voice", our clients, employees and the community, we realized the importance of housing that supports recovery and healthy families, and therefore, expanded our Mission to include the development and operations of supportive housing for homeless individuals and low-income families.   NAC now operates more than 600 units of permanent supportive housing layered with resident services that include partnering with organizations to provide tutoring for kids, leadership and empowerment training, financial literacy education, supplemental meal programs, nutrition and health related programming, job referral, life skills, cultural and art activities, urban gardening, and many other resident driven services.   One of NAC's strengths is developing and operating housing options for specialty populations including youth and seniors, disabled and/or persons with behavioral health issues, homeless, and people living with HIV/AIDS. 


What's on the horizon for Native American Connections is exciting, challenging and somewhat unpredictable.  It is always a challenge for NAC to balance the sophistication of layers of regulation, licensure, and clinical credentialing with our traditional Native healing and recovery approaches.  We value our clinical teams represented by mastered level and licensed clinicians, case managers, and peer recovery coaches as EQUAL members of the clinical team each bringing different perspectives and strengths to the recovery team.   Our peers are the heart and soul of NAC and are essential to the day to day operations and care of our clients.  NAC is highly experienced in integrating national approved program curriculum and clinical best practices with age-old healing practices that have existed and supported tribal communities for centuries.    NAC has a track record of preparing Native American behavioral health employees to master all the new ACA, HIPAA, and electronic medical record requirements making them some of the best qualified and prepared employees working within Native American programs throughout the US. 

In September 2014, NAC was awarded a 3-year federal SAMSHA grant to expand and enhance treatment and recovery services to addicted pregnant and postpartum women (PPW).   Based at Guiding Star, NAC's residential treatment center for women, the grant will also focus on enhancing services to all the children and fathers of the children, as well as the family members of the PPW clients.  NACs family program, Circle of Strength (COS), will be strengthened so that there is thoughtful inclusion of the healing and education that needs to take place for the families of the clients in treatment.  


"Talking Circle"

The SAMSHA grant will also offer synergistic support for NAC's construction of a new 60-bed residential Wellness Center that will open in May 2016.   The Wellness Center was co-designed with input from NAC's staff, an architectural firm, and 17 Arizona State University inter-disciplinary graduate students in architectural and landscape design, bio-informatics, recreation and physiology, and nutrition.   The students traveled with NAC staff to Australia to study "indigenous healthcare design" with the intent to design completely from a "facility wellness perspective".  Acquiring Institutional Review Board (IRB) approval, the students conducted more than 100 interviews and incorporated the voices of clients, staff, board members and community, and family members into the designing elements.   Highlights of the new Wellness Center include a 500 square foot circular "Talking Circle" room that has east-facing 12 foot doors that open to the outdoor environment.   Sacred spaces are landscaped for the sweat lodges that include gardens for the herbs used in the ceremonies.  And, there are numerous flex spaces for cultural and art therapy activities, health and recreation groups, primary care exams, and childcare areas.  Included within the center are transitional living units for family members and/or clients who need a "step-down" period before moving into a permanent housing situation.   The Wellness Center will be the new home of NAC's flagship programs Guiding Star and Indian Rehabilitation, and we believe that the Center will be at the national forefront for cutting edge treatment for Native and non-Native people who face the challenges of addiction.   


The notion of healthy mind, body and spirit, holistic approaches, or integrated health is neither new nor innovative when working in tribal communities.   They have always been the grounding principles for NAC because they are found within the language, culture and practices of the people we serve.  
Cultural Perspectives on Providing Psychiatric Care for the Latino Population

Amelia Villagomez, MD
By:  Sandra Combs, MD, PGY-4 Resident
        University of Arizona College of Medicine, 
              Department of Psychiatry, and


      Amelia Villagomez, MD

      Assistant Professor, Department of Psychiatry

      Child and Adolescent Psychiatrist

      University of Arizona College of Medicine

      University of Arizona -- UAHN South Campus


With the growing population of Latinos in the US population, it is becoming increasingly necessary for clinicians to be aware of effective means of treating Latino patients. According to the 2010 United States Census Bureau, the US population of Hispanic/Latino individuals increased 43% between the year 2000 and 2010 constituting 17% of the total US population .  In Arizona , this is of even greater significance as Latinos make up nearly 30% of the state's population.


The process of addressing shared features within any culture runs the risk of generalizing and oversimplifying a complex topic.  This does not cease to be true in addressing the topic of Latino culture. In fact, this is particularly true regarding the Latino community.  This group is comprised of subsets of individuals who culturally identify with a multitude of different countries of origin grouped together primarily due to sharing the common bond of the Spanish language in their ancestry. That being said there are certain features frequently observed within the Latino community.


It is commonly observed that within the Latino culture, individuals maintain close interpersonal relationships within the immediate family unit.  In addition to maintaining strong relationships within the nuclear family, most Latino individuals are also part of a greater support system consisting of  a tight-knit extended family and social community (Lim, 2006). 


Culture acts as a shaping template and includes a belief system which is taught and reproduced within a community.  It is important to keep in mind thatany culture is a dynamic entity which is not static but rather exists in a constant state of change (Grau, 2001). Our patients come to us often in a state of distress and seeking relief from symptoms related to mental illness.  Each time we engage in patient education we become an integrated component of this change.  The more effective and far-reaching we can be in this role, the more likely we are to see positive outcomes to our efforts.  For that reason, when appropriate,  educating family members may be a necessary component of effectively implementing treatment plans.  Not only does this serve as a means for providing better care to the individual patient, but it is equally important to establish an accurate understanding of mental illness and treatment within the patient's support system.  By working with families, in addition to the individual patient, the work we do in the clinic or hospital is reinforced where it matters most: in the patient's community and social support system.


There are currently several resources in place to offer culturally appropriate support to both patients as well as there families.  Some  resources to ensure our patients and their families are aware of include NAMI Arizona, NAMI Southern Arizona  and, all of which provide patient and family support in both English and Spanish.  At information can be found regarding resources available specific to the greater Phoenix area.  In addition to resources currently in place, there are also newly developing methods intended to continue the ongoing process of developing increased awareness of mental illness within the Latino community while working to resolve the negative stigmas too frequently associated with psychiatric illness.


One such method involves a return to the tried and true model of a grassroots  approach.  With this approach the role of educating a community is shared by various clinicians and community members alike.   This model allows for effectively extending  the educating we do in our offices into our patients' support network.  Also, and perhaps even more importantly, this model promotes taking ownership of the well being of one's community by putting the leaders of the very community we are treating in the driver's seat of the process. 


The Center of Excellence in Women's Health P.I.,  Francisco Garcia, and a dedicated team of mental health professionals have initiated clinician led training of members of the local Latino community who then return to their communities where they actively and systematically spread that education.  These community members are referred to as "promotoras".   Promotoras is a term referring to lay Latino community members who receive specialized training in order to provide basic health education in the community, in this case mental health education.  These individuals are often identified leaders within the community whose purpose is to return to their community with accurate information regarding mental illness as well as provide guidance in accessing community resources for diagnosing and treating mental illness.  Helpful to the process is that the model is a familiar one to the Latino Community.  The approach was first introduced in Mexico and subsequently adopted by countries throughout Latin America making the concept an approachable one.


The promotora model may not be ideal for every community, but the important message is to make sure and assess if family involvement and education is appropriate in the care of your patients.  If it is, then taking the time to inform our patients of resources available to them for obtaining additional education and support is frequently a culturally appropriate way to optimize the effectiveness of the treatment a psychiatrist provides. 


The authors would like to thank Dr. Francisco Moreno for editorial assistance.


Gaw AC:Concise Guide to Cross-Cultural Psychiatry.  Washington, DC, American Psychiatric Publishing, 2001.

Lim, Russel F:  Clinical Manual of Cultural Psychiatry. American Psychiatric Publishing, Inc, 2006.

Marin et al.: Mental Illness in Hispanics: A Review of the Literature. Focus, Winter 2006.

Preferred Room Rates Expire 1-16-2015; Register today for the UofA 2015 Update on Psychiatry (February 16-19, 2015)
Highlights from the APA Assembly (November 7-9, 2014), Washington, DC

Jehangir "Jay" B. Bastani, MD, DLFAPA APA Ben
Representative to the APA Assembly

1. Charles Price MD of Las Vegas NV is the new chair of the APAPAC, the APA Political Action Committee.  He presented recent national election results and the shift of party strength in the Congress, the APA stands to continue to benefit. Contributions have dropped considerably over several election cycles since 2008. Dr. Price urges us all to contribute to APAPAC.


2. Dr. Saul Levin MD reported as Medical Director and CEO of APA. Membership has risen 5% since last year, largely as a result of concerted efforts by the APA toward this goal. I was impressed in the transformation of the APA under his leadership over the past year from a Medical Director model to a CEO of a Corporation he envisioned last year. He shared his Strategic Partnership vision. APA has partnered with several MH groups to market a new consumer-friendly book, "Understanding Mental Illness". APA continues to fight for Mental Health Parity. Although a federal court ruling dismissed APA's case against Anthem, APA is developing new strategies to enforce MHPAEA, and working closely with States' attorneys general and insurance commissioners to develop enforcement guidelines. APA has launched a new Policy Finder tool on the APA website, and will be launching "Building a Career in Psychiatry" - a manual for students, residents  considering a career in psychiatry.  


3. Introduced at the past spring Assembly was the contentious APA Practice Guideline on the "Psychiatric Evaluation of Adults" that subsequently underwent revision and was passed by Assembly.  


4. The quick anticipated passage of "APA Position Statement on Firearm Access,  Acts of Violence and the relationship to Mental Illness and Mental Health Services" got mired in discussion and finally passed after deletion and revision of certain controversial statements in the earlier document pertaining to hunting firearms. 


5. This was the first time the District Branch (DB) Executive Director was invited to speak to the APA Assembly and the honor was reflected by the message given to us. Ms. Robin Huffman of North Carolina DB urged us to recognize and value the depth and diversity of skills among the current DB Execs. Many have advanced degrees in law, business, public health and registered lobbyists for their respective DB. All are involved in coalitions to support the concerns of MH and organized psychiatry. Like her colleagues, Ms. Huffman considers herself a "jack of all trades." The DB Execs have heard the message of the importance of increasing the value to the members and the need to collaborate towards that goal. Dr. Levin has instituted monthly conference call with DB Execs.  


6. The APA is doing well financially, with revenues exceeding budget from DSM 5 sales, other publishing revenues, membership receipts, and the Annual Meeting. Meanwhile, expenses have been well under budget, though expected to rise over budget before the end of the fiscal year. Membership dues, annual meeting and advertising budgets have remained strong and stable, while total membership has increased in the past year. Total reserves are growing, and have been growing steadily since 2009.  


7. Marie-Claude Rigaud from Chicago was this year's recipient of the APA Assembly's Profile of Courage award for her outstanding work in organizing mental health care as part of the relief effort following the earthquake that struck Haiti in 2010.  


8. Ronald Burd, Chair of the Committee on Codes and Reimbursement , spoke that SGR reform is going away. The emphasis is going to be on quality rather than quantity such as case-rate payments, bundled payments, and capitation. New chronic care CPT codes used by CMS are unlikely to be economically feasible. Commercial payer issues have settled down for now. For reimbursement, medical necessity sets the bar for services delivered. Documentation of time for E/M codes should be distinct from psychotherapy. Lack of documentation is the main cause of repayment requests from insurers. Medicare fee schedule will continue to be a challenge.

9. Two new workgroups of the Assembly met Saturday afternoon with Reps attending them. The Long Range Planning under Melinda Young MD chose to focus on the roles and responsibilities for AEC, Reps, Dep Reps, DBs and SA's. Plans include developing tool boxes for the Area and DB reps to do their jobs, and a questionnaire for APA Presidents and Presidents-Elect on the financial well-being of their DBs. The workgroup on Public Affairs under Jeffrey Borenstein that I attended, is defined by the Speaker to increase collaboration between Assembly and APA Foundation (APF). The committee will be developing a charter and the title of the workgroup to better reflect its liaison role with APF.


10.  Dan Anzia MD, Assembly liaison to Steering Committee on Practice Guidelines, spoke of upcoming guidelines on Management of dementia and Alzheimer's disease, Medication use for agitation in dementia, and the Treatment of bipolar disorder.


11. Action Papers that were amended and passed included topics such as Direct to Consumer Advertising, Telepsychiatry, Critical Psychiatrist Shortages at Federal Medical Centers, EHR for Psychiatrists, Training and Regulatory Standards for the Practice of Medicine Pertaining to the Treatment of Patients with Mental Disorders, Integrating Buprenorphine Maintenance Therapy with Primary Mental Health, Standardization of Psychiatric Nurse Practitioner Training ,  Assembly DSM Component, Exploration: Whether to Add Some Symptoms to the Next DSM and Use of terminology in DSM 5: Neurodevelopmental Disorder be used rather than Neurobehavioral. 


12. Canvassing was done by candidates for APA election, ballots for which should come out next month. Affecting our DB is the election of 3 Area 7 candidates to the Board of Trustees. They are Jeffrey Akaka MD from Hawaii who is the current Trustee and is for re-election; Annette Matthews MD from Oregon and Stephen Brown MD from Wyoming who was Area 7 recent past Area Representative to the Assembly. As your DB Representative, I am proud to say the slate of candidates are all hard workers and proven themselves over the years of my being Representative to the Assembly. 

"Parity Poster" Helps Patients Report Unfair Insurance Practices

The Mental Health Parity and Addiction Equity Act (MHPAEA) is clear that patients with a mental illness, including a substance use disorder, should no longer be discriminated against by insurers.  But how many patients know what constitutes a violation? Patients who know their rights are better equipped to protect their rights. 


That's why the American Psychiatric Association and the (DB/SA Name) have created a new tool to support parity enforcement: a poster titled, "Fair Insurance Coverage: It's the Law."  DOWNLOAD YOUR ARIZONA COPY TODAY.  


Written for lay people, the poster clearly explains the law and the steps to take when a violation is suspected.  Print out this poster and hang it in your office or waiting area or make it available as a flyer.  The contact information for the Arizona Department of Insurance has been included to assist patients.  


Then consider taking other steps:  Provide copies to colleagues for their offices, to clinics and hospitals, and even to employers who sponsor plans.  This poster, hung in a break room, will inform employees.  And it benefits employers:

  • Employees' health needs will be better met,
  • Employees will remain more satisfied with their benefits, and
  • Attendance and productivity will remain high, given the impact that illness can otherwise have.

This poster is only one of many steps that APA and APS are working together to strengthen enforcement.  It's a sensible step, as it supports patients and boosts the government's inspection and monitoring ability by putting more cases directly on its radar.  Attorneys general and state insurance commissioners can be powerful allies when they're informed of potential violations going on in their jurisdictions. 


Please join in fighting this form of discrimination and for equal access to mental healthcare.

Dr. Dine, AZ I See It, on Solitary Confinement
VISIT THIS LINK to read Dr. Max Dine, Community Liaison Member of the APS Executive Council, in an AZ I See It editorial, providing insights into why non-violent inmates should not be subject to the tortune of solitary confinement. 

Global Health and Cross Cultural Psychiatry
Traditional Dancing in Rwanda

By: Robin T. Reesal, MD, DABPN, FAPA

Dr. Robin Reesal, past Newsletter Chair of the Society, is working with his
wife, Helen Ewing, RN, DHSc, in Rwanda

The DSM-5 reflects the intertwined nature of cross-cultural psychiatry and global mental health.   


Section III of the DSM-5, titled, has ten pages devoted to "Cultural Formulation". The first sentence of this section captures the essence of the chapter (American Psychiatric Association, 2013), "Understanding the cultural context of illness experience is essential for effective diagnostic assessment and clinical management" (p.749).


The DSM-5 definition of culture in a psychiatric context is also relevant, (American Psychiatric Association, 2013) "Culture refers to systems of knowledge, concepts, rules, and practices that are learned and transmitted across generations" (p. 749).


Regarding global mental health, the DSM-5 uses the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) instead of the Global Assessment of Functioning Scale (GAF) (American Psychiatric Association, 2013). This change recognizes the role of global mental health and the interconnectedness of people and their mental health conditions. Standardization of mental health diagnoses and treatments serves to strengthen our profession's resolve to help those in need, regardless of origin or habitat.   


Cultural psychiatry case presentation*


This is a case of a 27-year-old single male, with no children, who was born in a resource poor country. He was adopted at age five and grew up in North America. The police found him fourteen days prior to his exam trying to hang himself in a park. He imprisoned for safekeeping. His embassy was called two days prior to his exam. During the interview at the prison, he said he came to his country of origin six months ago to "find himself". He overstayed his visa and did not pay his hotel bills. He said, "I do not belong anywhere." He had a history of multiple suicide attempts and hospitalizations. He continued to have passive suicide thoughts with no psychosis. The working diagnosis was bipolar I disorder recent episode depressed, alcohol use disorder, cannabis use disorder and borderline personality disorder.


Access to food, medical care, psychotropics and laboratory results were limited. There was one available  psychiatric hospital for the country. He had no money to buy medications or pay for treatment.


In this case, his embassy coordinated a trip back to his adopted country. They arranged with the local government to release him from prison and give him an exit visa, once his parents paid his debt. The embassy also arranged for the Red Cross to provide a nurse to escort him home where he would be transported to a hospital. The patient's family split the costs with the embassy.   


Butare Rwanda Hospital

Global mental health reality


The WHO Mental Health Action Plan 2013 - 2020 provides important statistics on global mental health (World Health Organization, 2013).


The global annual spending on mental health is less than US$ 2 per person. It is less than 25 cents per person in low-income countries. The WHO estimates that low-income countries assign 67 % of their mental health dollars to stand-alone mental hospitals, despite their association with poor health outcomes and human rights violations. For half the world's population there is one psychiatrist to serve 200, 000 or more people. Mental health legislation covers only 36% of people living in low-income countries compared to 92% coverage in high-income countries.


About 7% of countries worldwide have specific child and adolescent mental health programs (Sadock, 2015). In African countries, excluding South Africa, there are fewer than ten child psychiatrists (Sadock, 2015). In less than one third of all countries, is it possible to identify a specific government institution assigned to child mental health (Sadock, 2015).


According to the WHO (2013), every 40 seconds, a person dies by suicide somewhere in the world. For each adult suicide, there are more than 20 failed attempts. The most common means of suicide globally are pesticides, hanging and firearms.


According to the World Health Organization (2011), neuropsychiatric disorders make up about 13% of the world health burden. Sadly, over 75% of those with psychiatric disorders go untreated in low-income countries (Meyer, 2010).    


Are we different?


The South Africa's Sunday Times recently published a series of articles on mental health on July 6, 2014. The newspaper printed the following statistics: There was about 38 billion rand (3.5 billion USD) loss to the South African economy due to mental illness per year. About one third of South Africans suffer from "some form" of a mental illness in a year, with about 75 percent not having access to proper medical care. The mental health budget makes up only 4% of the national health budget.


According to the Substance Abuse and Mental Health Services Administration (2013) in 2012 close to 20% of Americans suffered from a mental illness.  Mental and behavioral disorders are the third leading cause of disability in the U.S. behind cardiovascular disease and neoplasm. (Murray, 2013). National Institute of Mental Health estimates the cost associated with serious mental illness in America to be about $300 billion per year (NIMH, 2014).


According to the World Economic Forum and the Harvard School of Public Health (2011), the global cost of mental illness is estimated to be $2.5T in 2010, which is expected to increase to over $6T by 2030 (Bloom, 2011). The annual GDP for low-income countries is less than $1T (Bloom, 2011).


While the numbers and countries change the essence of the challenges we face in mental health are similar.


Final words


The recent Ebola outbreak reminds we are part of a global community. North American is becoming a world mix, with the DSM 5's cultural formulation section reflecting the importance of culture and global health.  


*The case presentation is a composite of multiple cases (fictional), written for educational purposes and does not refer to a specific country.


Interesting websites:




American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders DSM 5 (Fifth Edition). Washington, D.C.: American Psychiatric Association.

Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S.,...  Weinstein, C. (2011). The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum.


Demyttenaere K., Bruffaerts R., Posada-Villa J., Gasquet I., Kovess V., Lepine J.P.,... Chatterji S. (2004).WHO World mental health survey consortium prevalence, severity, and unmet need for treatment of mental disorders in the world health organization world mental health surveys. JAMA,291,2581-90.


Meyer A.C., Dua T., Ma J., Saxena S., and Birbeck G. (2010). Global disparities in the epilepsy treatment gap: a systematic review. Bull World Health Organ,88,260-66.


Murray C.J.Abraham J.Ali M.K.Alvarado M.Atkinson C.Baddour L.M., ... Lopez AD. (2013). The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.JAMA, 310(6), 591-608. doi: 10.1001/jama.2013.13805.

National Institute of Mental Health. (2014). Annual total direct and indirect costs of serious mental illness (2002). .  December 3, 2014.


Sadock, B.J., Sadock V.A., and Ruiz P. (2015). Synopsis of psychiatry (eleventh edition), Philadelphia, PA; Wolters Kluwer.


Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.


World Health Organization. (2011). World Mental Health Atlas. Geneva, Switzerland: WHO Press.


World Health Organization. (2013). Mental Health Action Plan 2013 - 2020. Geneva, Switzerland; WHO Press.


World Health Organization. (2014). WHO Preventing suicide: a global imperative. Geneva, Switzerland; WHO Press.

Congratulations to Newest Distinguished Fellow and Fellow Members
JOIN US in congratulating Emerson Bueno, MD, DFAPA, on his election to Distinguished Fellow of the American Psychiatric Association.  This distinction recognizes Dr. Bueno for a career that has made significant contributions to the field of psychiatry.

ALSO JOIN US on congratulating the following members of the Arizona Psychiatric Society newly approved for Fellow status in the APA:  

Susan H. Baumann, MD, FAPA
Ankur Bindal, MBBS, FAPA
Melissa M. Campbell, MD, FAPA
Amanda M. Catellino, MD, FAPA
Darwyn B. Chern, MD, FAPA
Dennis M. Friedman, DO, FAPA
Thomas David Gazda, MD, FAPA
Aimee C. Kaempf, MD, FAPA
Yukari Kawamoto, MD, FAPA 
Shubha N. Kumar, MD, FAPA
Gwen A. Levitt, DO, FAPA
Juan C. Pequeno, MD, FAPA
Roland Segal, MD, FAPA
Monica J. Taylor-Desir, MD, FAPA
Jacob Venter, MD, FAPA
Sarah Wicklund, MD, FAPA
Shabnam Woerner, MD, FAPA

The honor of Fellow reflects the dedication of these members to the work of the APA and the psychiatric profession.  

The distinctions awarded these members will be honored during the 58th Convocation of Distinguished Fellows ceremony during the APA Annual Meeting in Toronto, Canada.  For more information on becoming a Fellow or Distinguished Fellow of the APA, VISIT THIS LINK.  The application for Distinguished Fellow must be submitted by the District Branch.  If you are interested in learning more about that nomination process, please contact Teri (, 602-347-6903).  
Educational Events 
Grand Rounds for the Department of Psychiatry of Banner Good
Samaritan Medical Center will resume on Friday, January 9, 2015, and are held from Noon to 1:00 pm, in the Medical Education Amphitheater (unless otherwise indicated).  For the full January Agenda, CLICK HERE.

APA Online Can Help You Meet Your December 31st CME RequirementsAPA free education highlight
Do you need to report your CME by December 31?  APA has dozens of online CME activities at, and many are free for APA members.  Courses include Practice Guidelines; DSM-5; Performance in Practice Modules; eFocus clinical vignettes; Buprenorphine training; addiction psychiatry webinar series; and much more.  Enter self-reported credit on your transcript.

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

Saturday, February 21, 2015, "Sibling Relationships and Sibling Transferences:  Timeless Perspectives From Fairy Tales"; Speaker Jean Goodwin, MD.  Click Here for Flyer.

Saturday, April 25, 2015, "Somatic Experiencing:  Expanding the Psychodynamic Dialogue"; Speaker David Levit, PhD, ABPP.  Click Here for Flyer.
Stay Tuned:  First Monday Kaffe Klatch to Resume February 2, 2015; Health Care Reform Workshop Dates Being Reset
First Monday Kaffe Klatch, a collegial discussion group hosted by Dr. Martin Kassell, will be taking off the month of January for the holidays.  The group plans to resume on the first Monday in February (February 2nd) and will determine its 2015 meeting dates at that time.

The January 8, 2015 and January 10, 2015 Health Care Reform Workshop dates are being rescheduled and a member mailing will go out at the first of the year with these new dates.