September 2015
In This Issue

From the Newsletter Chair
Monica J. Taylor-Desir, MD, MPH, FAPA
September 2015

Welcome to the first few days of fall! In this issue we highlight correctional psychiatry.  Just as the weather changes with the approach of fall and in some areas of the state, the leaves actually change, Dr. Theinhaus discusses the change in view of correctional psychiatry from a last resort to its own field of study.   In some states, the justice system has become the de facto psychiatric caregiver for many. He highlights several aspects of the field of correctional psychiatry and the utility of developing various clinical skills in this environment including the identification of the social determinants of mental health. Dr. Reesal continues to provide us with a global perspective on various aspects of mental health. In this issue, he writes about the global perspective of violence. Please peruse the article on the Stepping up Initiative to fight the criminalization of mental illness and determine how you can contribute to the change in perspective in mental health issues. Dr. Olson and Mr. Abate provide us with a legislative update on AHCCCS and the Sunrise Application submitted by the Arizona Nurses Association. Last but definitely not least, Dr. Sadr and Dr. Marwah share the Area 7 Assembly Report with an invitation to meet the Area 7 representatives during the weekend of March 5-6th, 2016. You don't want to miss that opportunity to collaborate with psychiatrists from other states in an informal atmosphere. You will find many exciting local educational opportunities listed.  Be sure to save the date for the APS Annual Meeting - April 30, 2016 and take a moment to complete the planning survey. We hope to connect with many of you in the coming months now that the weather is cooler!  Enjoy this issue. 

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Roland B. Segal, MD, FAPA
Arizona Psychiatric Society, President

As the Arizona Psychiatric Society, we must advance our profession by focusing on the highest quality of patient care. Not only does this entail self-scrutiny within our own practices, but also broader advocacy within the legislation of Arizona. To this end, our Executive Council and Legislative Committee have a strong, working relationship with lobbyist, Mr. Abate, and we have been able to work both defensively and proactively to ensure Arizonan's safe and effective psychiatric care. Our society has been working diligently to make certain that psychologists, who have not had the rigorous years of medical training essential to the safe and effective prescribing of psychiatric medications, are not allowed to place patients at risk by prescribing. Our society has spoken up to prevent changes to the Arizona Statutes that may have potential for negative outcomes, including merging of large insurance carriers and more restricted AHCCCS. 
Despite our lobbying efforts, advocacy, educational programs and social events, almost half of the psychiatrists in Arizona are not members of APS. Perhaps they either do not know about the society, or do not see the value in joining. This year, we must strive to engage these non-members, and we need your help. Educate non-member colleagues about the society, its work, and its benefits, and encourage them to join. There is strength in numbers. Each year brings new challenges to our profession, and we need this strength.
I am open to your ideas and thoughts and look forward to a great year working together. 

Ole J. Thienhaus, MD, MBA, FACPsych, DLFAPA
Professor and Department Chair
University of Arizona College of Medicine

Not so very long ago, working as a psychiatrist in a jail or prison would have been considered an option for those who had no other choices. This was a time when graduates of residency programs saw a private solo practice of psychoanalysis and psychodynamic therapy as the natural career after graduation, a time when pharmacotherapy was seen as an unfortunate adjunct, when Board certification was optional and psychiatric diagnoses took a backseat to psychodynamic formulation.

Much has changed since those days. Correctional psychiatry is a respected practice area with its own body of service research, attracting some of the finest professionals in the field, and held to the highest standards of practice.  Every year, at least one of our graduating residents at the University of Arizona chooses a career in the correctional sector. A natural corollary of these developments is the emergence of correctional psychiatry as a defined area of graduate training.

First a point of clarification. Correctional psychiatry is not forensic psychiatry. Rather, it is the practice of general clinical psychiatry in a particular setting, namely in state and federal prisons and in detention centers. Its closest relative is the venerable concept of community psychiatry.

It has been well documented that psychiatric disorders are highly prevalent among incarcerated individuals in the US. On its website (http://nicic.gov/mentalillness), the National Crime Information Center (NCIC) states that "[I]n a 2006 Special Report, the Bureau of Justice Statistics (BJS) estimated that 705,600 mentally ill adults were incarcerated in state prisons, 78,800 in federal prisons and 479,900 in local jails. In addition, research suggests that 'people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four times the general population' (Prins and Draper 2009)." Prevalence figures vary widely, often because of different inclusion criteria. But even when antisocial personality disorder, substance use disorders and adjustment disorders are excluded, it is likely that psychiatric diagnoses are more common among detainees than in the population at large. And of course, adjustment disorders and substance use disorders deserve psychiatric attention as well as schizophrenia and OCD.

Thus there is an epidemiological imperative to expose mental health professionals to an environment that is home to a substantial proportion of their clientele. In certain jurisdictions, prisons have more psychiatric beds than all state hospital facilities combined (Torrey et al. 2010). This situation is hoped to change somewhat in the future as states and the federal government are beginning to rethink their incarceration policies and to reform sentencing guidelines. But those changes are unlikely to result in drastic shifts in the short and intermediate term so that the epidemiological reason for investment in correctional psychiatry training will exist for many years to come.

Besides, there are some specific experiences that make training in jails and prisons exceptionally valuable. Many facts about our practice environment in other settings apply to corrections, but are more explicit here and require consideration by the trainee. This prepares the professional to address similar issues in other environments where they may be harder to spot. Because systems-based practice is one of the dimensions of competency in the new Milestones concept of competency acquisition and evaluation promulgated by the Accreditation Council of Graduate Medical Education, a training site that provides experience in this area is of particular interest to program directors.

Dual loyalty
Military psychiatrists have long been familiar with the unique demands placed on professionals responsive to both their professional standards of practice and the rules of the institution that employs them. In jails and prisons a similar situation applies. Both institutions serve the primary purpose of containing individuals safely, with prisons having an added function of punishment and rehabilitation. The correctional setting provides an ideal laboratory to learn about working in a setting of dual loyalties. Weighing the needs of maintaining a safe environment while developing an individualized treatment plan for a mentally ill inmate brings into clear relief competing priorities that are often more subtle in other contexts. In principle, however, the same considerations apply when treating a patient while observing a managed care insurer's prescribed algorithm for trying certain medications first before prescribing more expensive ones, or when justifying continued hospitalization to a utilization manager.

Since the massive involvement of privately owned healthcare management companies in the delivery of services in the correctional setting, the issue of dual loyalty has acquired an additional dimension. No longer is it only the public sector's interest in the primary purposes of confinement, but the agenda of the management company as well, that competes with the clinician's primary allegiance to his or her professional standards.

The subtle, often unconscious emotional reactions patients stir in their doctors may go unnoticed in daily practice unless specifically teased out in psychodynamically informed supervision. The correctional setting forces any clinician to come to terms with their countertransference (Brown 2007). Even though inquiry into the criminal background is not part of the inmate's medical or psychiatric examination, more often than not the reason for incarceration is well-known to the clinician. It takes a great deal of practice and, ultimately self-knowledge, to conduct an empathic interview with a patient in jail whom last week's headlines depicted as a sadistic child murderer. This is an exercise that no serious clinician can avoid if he or she wants to avoid contamination of the doctor-patient relationship by their personal feelings. Again, it is the uncompromising starkness of the correctional setting that can serve as an outstanding laboratory to learn about this aspect of our care.

Limited resources
Since part of the triple aim of the Institute of Medicine is cost-effective care, much attention in all practice settings as well as in medical education and training is being paid to the financial aspects of patient care. The quasi-closed system of a correctional setting, especially a prison, gives concrete meaning to the trade-offs that occur when the cost dimension of care is ignored. A fixed budget, set either by the public entity in charge of the facility or more commonly the correctional health care managing company, drives home the point that, for instance, unrestrained prescription of non-formulary brand medications is likely to lead to reduced availability of therapeutics for other inmates.

Integrated care
Integrated care is currently a major focus of attention in psychiatric practice design. It is a defining characteristic of Arizona's new round of Regional Behavioral Health Authorities (RBHA), several new books by psychiatric publishers have appeared on the topic (Raney 2014), the American Psychiatric Association has established a Workgroup on Integrated Care, and it is an explicit or implied component of the new value-driven models spawned by the Affordable Care Act of 2010.

In Corrections, collaborative care has been a reality since long before it became fashionable. The close collaboration with primary care physicians is a daily routine for the correctional psychiatrist, including frequent "huddles," i.e. informal information exchanges about patients and clinical issues. But beyond the interaction with primary care, the jail or prison also fosters close collaboration with chaplaincy, psychology and social work. Even more than in a typical community mental health center, for example, the clinician in a correctional facility is confronted with all aspects of the patient's life. Compartmentalization becomes counterintuitive (Tarasoff and Thienhaus, 2013). 

Secondary gain
The vast majority of inmates who request psychiatric services or are referred by corrections staff or other health care professionals have legitimate reasons to see a mental health clinician. However, the potential for exaggerated or, more rarely, fabricated complaints is higher than in most other practice settings. The reason is that, especially in prison, the potential of immediate benefits due to being a patient can be more obvious and immediate than elsewhere. For example, the food in an infirmary setting may be better, the social isolation less oppressive and the risk of exposure to violent peers more contained. Here, the educational value is the need to learn careful operationalization of such secondary gain potential. For every teacher who has worried about the readiness with which psychiatric trainees get acclimatized to terms such as "frequent flyer," "med seeking," "malingering" and "attention-seeking behavior," the opportunity to expose residents to the corrections environment should be welcome. Familiarity with psychometric tools to quantify probability of a fraudulent clinical presentation (Adetunji et al. 2006) will be the most effective inoculation against the temptation to assign "diagnoses" of malingering based on countertransference or preconceived notions in the clinical environment. The psychometric approach is meant to inform clinical decision-making even in the absence of formal testing.

Forensic issues
As mentioned above, correctional psychiatry is not forensic psychiatry. In fact, the "red zone" between the two has to be scrupulously observed (Burns 2007). However, the presence of forensic issues as primary environmental factors is indisputable in virtually any psychiatric evaluation and psychodynamic formulation of patients in a correctional setting. As discussed elsewhere (Rahe et al. 1970), the impact of the criminal justice system must always be considered a major precipitant factor in the acute psychiatric manifestations of an inmate. In the jail, the very fact of arrest usually involves secondary implications of family cohesion, financial security and employment for the inmate. In prison, the enforced separation from spouse and family, the inherent induction of hopelessness by a denied appeal, the specter of the death penalty must all be considered significant factors stressing the psychological coping skills to a maximum.

Sensitivity to social justice
The majority of people behind bars are poor. Many are people of color. The problems inherent in incarcerating substantial swaths of our population who are economically disadvantaged has received a great deal of attention lately. Even more than state hospitals, community mental health centers and emergency departments correctional facilities introduce medical trainees to sections of American society they have probably had little exposure to before (Kaempf et al. 2015).

The realization that behavioral health is determined not only by genetic endowment, not only by factors in upbringing and parenting skills and ensuing attachment, is a necessary corrective to the clinical training experience. It is not confined to the correctional setting. But jails and prisons are places where the fact is so prominently part of the clinical understanding of the patients' predicament that no trainee will forget this lesson as they transition to other clinical practice sites.

In summary then, the epidemiologic mandate is complemented by an array of specific learning objectives for which the correctional settings provides an exceptionally rich experiential opportunity. The exposure to the correctional environment further is probably the best recruiting tool for professionals to contemplate a career in this sector. This can only improve the long term outlook for access to care for all of our patients.
Adetunji BA, Basil B, Mathews M, Williams A, Osinowo T, Oladinni O. Detection and management of malingering in a clinical setting. Prim Psychiatry 2006; 13:61-69
Brown GP. Countertransference in correctional settings. In Thienhaus OJ, Piasecki M (eds.): Correctional Psychiatry, Volume 1. Kingston, NJ, Civic Rights Institute, 2007, pp. 11-1 to 11-11
Burns KA. The Red Zone-Boundaries of clinical vs. forensic work in correctional settings. In Thienhaus OJ, Piasecki M (eds.): Correctional Psychiatry, Volume 1. Kingston, NJ, Civic Rights Institute, 2007, pp. 19-1 to 19-10
Haney C. The psychological impact of incarceration: Implications for post-prison adjustment. The Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services. aspe.hhs.gov, 2001
Kaempf A, Price E, Thienhaus OJ. Residents' knowledge of social concepts affecting their patients. Acad Psychiatry 2015;27 (In press)
Prins SJ, Draper L. Improving outcomes for people with mental illnesses under community corrections supervision: A guide to research-informed policy and practice. Council of State Governments Justice Center, New York, 2009, pp.1-42. ImprovingOutcomesForPeopleWithMentalIllness.pdf
Rahe RH, Mahan JL, Arthur RJ. Prediction of near-future health change from subjects' preceding life changes. J Psychosom Res 1970; 14: 401-406.
Raney LE (ed.). Integrated care. Washington DC, American Psychiatric Publishing, 2014
Tarasoff G, Thienhaus OJ. Collaboration with other disciplines. In Thienhaus OJ, Piasecki M (eds.): Correctional Psychiatry, Volume 2. Kingston, NJ, Civic Rights Institute, 2013, pp.2-1 to 2-27
Torrey EF, Kennard AD, Eslinger D, Lamb R, Pavle J. More mentally ill persons are in jails and prisons than hospitals. A survey of the states. warren.pa.networkofcare.org, 2010 

The Planning Committee is working to invite speakers for the Arizona Psychiatric Society Annual Meeting, set for Saturday, April 30, 2016. If you did not respond to the invitation to participate in the Annual Meeting Survey previously distributed, your input can still help shape the topics lined up for a great day of education on "Innovations in Psychiatry."  

The American Psychiatric Association Foundation has joined other leading organizations in support of the Stepping Up Initiative, an unprecedented national collaboration designed to generate action in communities across the country for a common goal: to reduce the number of people with mental illnesses in U.S. jails.
The number of people with mental illnesses in U.S. jails has reached a crisis level: two million individuals with serious mental illnesses like schizophrenia, bipolar disorder, and major depression are admitted each year, many of whom also have drug and alcohol use problems. Allowing them to continually cycle through jails does nothing to improve public safety, stresses already strained budgets, and hurts people with mental illnesses and their loved ones.

How You can Help
Visit American Psychiatric Foundation Association to find out how to get involved with the Foundation and support its outreach.

Does your family, office, or health care institute participate in NAMI Walks?  We would love to recognize your efforts in our community.  Send your photo or your story to teri@azmed.org.   
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LEGISLATIVE UPDATE: Comment on Modernizing Medicaid Arizona by September 25, 2015; APRN Sunrise Application by Nurses in 2015

Carol K. Olson, MD, FAPA
Legislative Chair

For a summary of the provisions of Governor Ducey's Modernizing Medicaid Arizona proposal, CLICK HERE.  Dr. Carol K. Olson, together with Dr. Alicia Cowdrey, prepared comments from the Society regarding concerns over terms of the proposal that could be barriers to care.  

CLICK HERE to read those comments, which were submitted to AHCCCS and the Office of the Governor.  You also have the opportunity to comment.   The deadline for submitting questions, concerns or comments is Friday, September 25th.  Submit your comments in writing to:  AHCCCS, c/o Office of Intergovernmental Relations, 801 E. Jefferson Street, Mail Drop 4200, Phoenix, AZ 85034 or via e-mail at publicinput@azahcccs.gov.
Joseph F. Abate, Esq.
APS Lobbyist

There were only three Sunrise Applications filed prior to the September 1, 2015, one of which has possible ramifications to the practice of psychiatry.  This Sunrise Application was filed by the Nurses Association and can be downloaded from their website at http://www.aznurse.org/.  Stakeholders are meeting with the Nurses Association to provide comment upon and for the opportunity to review the draft legislation that is proposed to be presented should the Sunrise Application be approved to move forward.  That Sunrise Hearing will be November 4, 2015.  
Dr. Sadr and Dr. Marwah enjoyed a walking tour of Portland
Portland Oregon, August 2015

Payam Sadr, MD, FAPA
Gurjot K. Marwah, MD
Arizona Assembly Representatives

Dr. Payam Sadr and Dr. Gurjot Marwah both attended the Area 7 Assembly Meeting in Portland, Oregon from August 6-7, 2015.  The restructure of the APA Assembly representation has changed Arizona's representation from one Assembly Representative and one Deputy Assembly Representative to two Assembly Representatives, and the Area 7 funded the travel for both Arizona Assembly Representatives.  This is an exciting change. 
Dr. Zarling discussed the AEC meeting July 24-26 in Montreal, Quebec, Canada and following are highlights of note from those leadership reports:
  • Practice Guidelines review of elderly and antipsychotics deadline September 19th,
  • DSM Assembly Committee to report to Procedures,
  • Medical Director (Saul Levin) reported a 4.4% growth in membership, with International growth at 26%; dues paying growth at 3.1%, ECP growth at 2.3%, and RFM growth at 4.6%.
  • Phil Wang hired as Director of the Division of Research coming from being the Deputy Director of NIMH.
  • David Keen hired as CFO having been the Finance Director of the American Federation of Federal Employees.
  • Brian Smith hired as Director of State Government Affairs.
  • The Board of Trustee's has approved the lease of the top three floors of a development at the WARF for three years with an option to purchase in 2020. This would be an anchor property.
  • APA strategic priorities are: advancing psychiatry in the health system, support research, education, and diversity.
  • Under comunications a new website soft launch in September 2015,
  • ICD-10 instructions become effective in October;
  • A psychopharmacology section will be included in the newsletter.
  • Under Advocacy, the Murphy Bill (HR 2646) was reintroduced which included inducements in the workforce, and annual parity compliance reporting among other things.
  • The recent insurance company mergers are concerning and are being looked at by CAGR and the AEC among others.
  • The reviving of the State Legislative Advocacy Conference will be in October and four field Reps will be hired to support DB legislative work.
The Assembly workgroup on Minority and Underrepresented Groups (MUR) issues was discussed by Linda Nahulu (Chair of MUR). And the Assembly is asked to be mindful of diversity in its many forms when electing Representatives to the Assembly. Assembly workgroups kept were Access to Care, MOC, Membership, others were retired or combined to work to optimize the Reference Committee process. A new President's Award has been established for the highest percent of members of a DB voting in the annual elections.
Speaker Glenn Martin discussed APA strategic priorities and the importance of Area 7 in the Assembly and the APA with acknowledgement of the challenges that geography and sparsely populated states brings to our organization and that the restructuring of the Assembly, in part, reflected this. He discussed the Joint Reference Committee (JRC) and Board of Trustees (BoT) disposition of the various Action Papers. He discussed several strategies to increase the effectiveness of Reference Committees. The Assembly DSM Committee was approved. The BoT approved procedures for making changes to the DSM. DSM-5 may be slowed in changing due to several technical reasons except for essential content. He discussed several workgroups including Access to Care, a Matrix workgroup, a workgroup on Assembly/Foundation Initiatives, The Foundation is looking for new funding streams.
Matt Sturm gave a report from the APA staff and from his position in the Department of Government Relations. The State Government Relations infrastructure will be upgraded to include four regional coordinators. A State Government Relations Director was hired, Brian Smith (bsmith@psych.org) who will bolster the work being done by Janice Brannon and Pamela Thornton. They will staff the State Advocacy Conference. It was noted that Alaska is in a transition state and needs help soon. The Tim Murphy Bill was discussed as well as the insurance company mergers.
Dr. Price reported regarding APAPAC.  The rollout of APA-CAN was discussed. This is an initiative to pair up every member of the House and Senate with an APA member. Also the initiative to follow the lead of the Assembly Executive Committee and have 100% of Area 7 contribute to the APAPAC. Area 7 is one of the leading Areas in this effort to date.
Regarding registries:  If you can't measure it, you can't improve it.  Numerous entities (congress, payors, patients) are now demanding concrete measures of improvement. What is clear is that if we don't establish our own standards of measurable improvement in medicine, then others will, and that specialties that have adopted them (Ophthalmologists, Neurologists) are showing measurable improvements in the outcomes of their patients through establishing registries.  Although numerous challenges exist, including cost, and perhaps more concerns for psychiatry about confidentiality, the BOT voted to have the APA administration develop a business plan to explore how we might create registries for quality improvement for psychiatrists.
DSM Steering Committee:  The BOT voted to approve
1)  the "Format for Submissions of Proposed Changes to the DSM"
2)  the Creation of six DSM Review Committees
3)  several corrections to DSM 5 that were needed
Dr. Sadr and Dr. Marwah were warmly welcomed to the Area 7 Assembly group, this being Dr. Sadr's first official meeting as Assembly Representative (having attended in the past as a Deputy Representative) and Dr. Marwah's first Assembly gathering.  They reported it very beneficial to hear the different approaches to similar membership, advocacy, and practice issues from each of the other States, and enjoyed greatly the collegiality with the representatives from all of Area 7 (Hawaii, Idaho, Nevada, Oregon, New Mexico, Washington, Montana, Colorado and West Canada).  The Area 7 voted to bring its Spring Meeting to Phoenix, Arizona, with the hope that Dr. Marwah will host them for dinner.  It is hoped to also plan a reception for Arizona Psychiatric Society members to be given the chance to meet with the representatives from the other states in Area 7 during that meeting weekend (March 5-6, 2015).  Hope you will save the date! 
Ugandan Women Gather
Robin Reesal, MD

Violence is widespread and a long-standing thorn in humankind's side. This article provides a brief over view of global violence.   

Defining violence
The World Health Organization (WHO) defines violence as "the intentional use of physical force or power, threatened or actual, against oneself, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation." Violence can be divided into self-directed, interpersonal and collective. This article focuses on interpersonal violence.

How often are people killed?
There are more than 1.3 million violent deaths each year in the world. From 2000 to 2013, about 6 million people died by acts of interpersonal violence which is more than the deaths from all wars during that time, according to the WHO.
There were an estimated 475 thousand homicides worldwide in 2012. The highest rate of homicides in the world is in the 15 to 29 age group, 10.9 per 100,000 vs 6.7 per 100,000 for all age groups. Males account for 82% of all homicides in this age group.

Globally, close to 40 percent of female homicides are at the hands of an intimate partner and about 41,000 children under the age of 15 are killed yearly.  

The WHO has identified some regional patterns. The Americas (North and South America) have the highest homicide rates in the world at 28.5 per 100, 000 population. The U.S. homicide rate, according to the CDC, is 5.1 per 100,000 with firearms accounting for 3.5 per 100,000 homicides.  The African Region homicide rate is 10.9 per 100,000 population. The low and middle-income countries in the western pacific region have the lowest homicide rate of 2.1 per 100,000.

Is the homicide rate changing?
From 2000 to 2012, the global homicide rate dropped by 16 %. For high-income countries, the rate has dropped by 39 %. 

What are the favored weapons?
Close to fifty percent of homicides are committed with firearms. Firearms are more commonly used in the Americas, while knives, beating with fists and other objects are more commonly used in other parts of the world.
What about abuse?   
Women, children and older persons are most vulnerable to violence. A quarter of all adults, globally, report being physically abused as children, according to the WHO. One in five women and one in thirteen men report sexual abuse as a child. One in three women report sexual or physical abuse by an intimate partner, at some point in their life. The global estimate of elder abuse is about 6%. As the global population ages the older person will be more susceptible to abuse, neglect and exploitation.

What are the consequences of violence?
Globally, an estimated 42% of women, physically and/or sexually abused by a partner, experience physical injuries. Victims of violence are at greater risk for substance use disorders, depression, PTSD, eating disorders, high-risk sexual behavior, and suicide. The physical and psychological injuries from violence can be severe and lifelong. They usually coexist needing interprofessional collaboration. Nuclear and extended families, communities, judicial systems and workplaces are woven into the fabric of interpersonal violence. The interplay of people and systems within communities is a global pattern.

What are the costs?
For 2004, the direct and indirect costs of violence accounted for 0.4% of the gross domestic product of Thailand, 1.2% of the GDP for Brazil and 4% of the GDP of Jamaica. The overall costs to the Canadian economy because of violence against women was estimated as 4.8 billion CND dollars in 2013. Statistics from the U.S. in 2003 show the economic costs of violence against women was about 5.8 billion dollars per year. Based on 2010 information we spend about 124 billion dollars per year on direct and indirect costs dealing with child maltreatment.

What can be done?    
Most of the information for this article comes from the "Global Status Report on Violence Prevention 2014" a joint report by the World Health Organization (WHO), United Nations Office on Drugs and Crimes (UNODC) and the United Nations Development Program (UNDP). This evidence-based document proposes a global template for violence prevention.

This group highlights the need for better data collection.  In their view, "...sixty percent of countries do not have usable data on homicide from civil or vital registration sources." Because violence is under reported they emphasize the need for population-based surveys.

The strategies for the prevention program are: "1. developing safe, stable and nurturing relationships between children, their parents and caregivers; 2. developing life skills in children and adolescence; 3. reducing the availability and harmful use of alcohol; 4. reducing access to guns and knives; 5. promoting gender equality to prevent violence against women; 6. changing cultural and social norms that support violence; 7. victim identification, care and support programmes."
Is a summary possible?
One cannot adequately summarize global violence in a paragraph, an article or even a book. Presenting statistics on fatal and non-fatal interpersonal violence, the aftermaths of violence, the financial costs of violence and ways to address the problem is a sterile representation of a deeply personal, emotional and painful topic. 
When I asked an African nurse who had been held hostage as a child, assaulted and rejected by her village, "How did you find the courage to continue?" She answered, "I was determined to find a way to survive and help others who have gone through the same experiences..." The term invulnerable child comes to mind.
Life in Africa exposes the weaknesses and strengths of humanity. The stories I hear are of heartbreak and courage.

The United States Government's international program for gender-based violence can be accessed at:  https://www.usaid.gov/gbv  
Changes Effective October 1, 2015

Beginning Oct. 1, all HIPAA-covered entities must transition to using ICD-10 codes. The new codes are listed in the DSM-5, along with the ICD-9 coding. More information about the switch to ICD-10, including a brief tutorial video, is available on the APA website.

BannerGrand Rounds for the Department of Psychiatry, Banner-University Medical Center Phoenix:  September 25, 2015, 12:00 Noon to 1:00 pm, Medical Education Amphitheatre, "Metabolic Monitoring for Patients Treated with Antipsychotic Medications," Bradley Zehring, DO, PGY-3 Psychiatry Resident, Banner-University Medical Center Phoenix

Arizona Psychological Association, 2015 Annual Convention: Trending Topics in Research & Practice #Co-ordination of Care, October 16 and 17, Carefree Resort, Carefree.  Online registrations accepted through October 15, 2015.  

ASU Center for Applied Behavioral Health Policy in partnership with Arizona DHS
October 30, 2015 - Scottsdale, Arizona
Fairmont Scottsdale Princess Resort

Join  Institute for Mental Health Research for an evening with Judith Rapoport, MD, Chief of Child Psychiatry, The National Institute for Mental Health
Advances in Children's Mental Health Treatment and Research
Thursday, November 5, 2015, 6:00-8:00pm
Phoenix Children's Hospital, Mel Cohen Conference Room in the Rosenberg Children's Medical Plaza
Registration fee: $40 ($30 for students and interns).  Please RSVP to Carol@IMHR.org or 602.321.5738 by October 23, 2015.

Featured Speaker:  Paul Holinger, M.D.  

Affect Theory and the Impact of Trauma On Early Development:  Implications for Child and Adult Treatment

9:00am - 4:00pm, Hacienda del Sol Guest Ranch Resort, 5501 N. Hacienda del Sol Road, Tucson, AZ

Saturday, November 21, 2015, 8 AM to 4 PM, Black Canyon Conference Center
Register early for a discounted rate of $75 for AZ Psychiatric Society and AzSAM Members, $35 for Students/Residents.  After November 1, 2015, rates will increase by $20.  A limited number of scholarships are available for students and residents.  

2016 Update on Psychiatry:  Highlighting Integrated Care, February 15-18, 2016, in Tucson, Arizona at the Westin La Paloma.  This four-day, live accredited, expanded Psychopharmacology Review Course, will highlight experts in the field of clinical psychiatry, primary care, and psychology to present cutting edge information as it relates to depression, addiction, pain management, and psychotic disorders in a format that permits in-depth exposure and an intense learning experience.  Excellent, nationally renowned presenters include:  Rakesh Jain, MD, MPH; Tamsen Bassford, MD; Henry Nasrallah, MD; Melissa Piasecki, MD; Charles Raison, MD; and Steven Galper, MD, JD.  Attendance will provide valuable impact in your daily practice and help you prepare for Maintenance of Certification by the American Board of Psychiatry and in your specialty.  

The APA needs additional providers to opt-in to the Find-A-Psychaitrist database being compiled by the APA in order to make it available nationally and locally.  If you are in a practice setting and accepting patients, help support access to care in our community by completing your opt-in today.  If you have any questions or need any assistance, please contact APA Customer Service atapa@psych.org or call 1-888-35-PSYCH or 1-888-357-7924.