WINTER NEWSLETTER
December 2015
Volume 6, Issue 4
In This Issue
PRESIDENT'S MESSAGE
ARIZONA RFM RUNNING FOR APA RFM TRUSTEE ELECT
APA FELLOWSHIP APPS DUE JAN 30
TREATING SUBSTANCE RELATED DISORDERS IN VETERANS
APA ANNUAL MEETING AND JANUARY PSYCH PICNIC SIGN-UPS
BRIDGES TO RECOVERY
NEW PSYCHOACTIVE SUBSTANCES
NEW SCHIZOPHRENIA TREATMENT OPTION (Sponsored)
LEG UPDATE: NURSE'S SCOPE OF PRACTICE
APA CALL TO ACTION ON CRIMINAL JUSTICE AND DEFINITION OF PHYSICIAN
ASSEMBLY REPORT FROM APA
CECIL THE LION, AN AFRICAN PERSPECTIVE
PHOTOS FROM RFM FALL MIXER
MS FOR THE NON-NEUROLOGISTS
FIND-A-PSYCH OPT-IN
Quick Links



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

As we approach this holiday season we instinctively look back over the year and review our joys, losses, accomplishments and set new goals. Looking back we have a review of the Multiple Sclerosis for Non-Neurologist Conference presented by Cleveland Clinic in September. Looking ahead we have a greeting from one of our very own RFM who is running for APA RFM Trustee elect. Since our last issue we in Arizona were touched by campus violence at Northern Arizona University. Our society had an opportunity to reach out and offer support to the campus community. Dr. Reesal has provided an article that challenges our perspective on what is reported on the media in light of what is happening on a world stage.
This issue of the newsletter highlights addiction psychiatry. This is the time of the year to share good cheer and holiday spirits. This can be a difficult time of year for those facing addiction. Tariq Ghafoor, MD and guest co-author, his son, Bahoo Ghafoor, MS-4 have submitted a very scholarly article reviewing designer drugs. Carlos Carrera, MD, DLFAPA has submitted an article on treating substance related disorders in Veterans.  We are pleased to also be able to share an article originally published in the Maricopa County Medical Society magazine, "Roundup," authored by Michael Sucher, MD, on understanding addiction to pain killers triggered by chronic pain.  The concept and practice of gratitude is very important for those in recovery. As we take time this season to appreciate the good things in our life and the patients that allow us to walk along with them in their journey I am reminded of the seven benefits of gratitude:
1. Gratitude opens the door to more relationships
2. Gratitude improves physical health
3. Gratitude improves mental health
4. Gratitude enhances empathy and reduces aggression
5. Grateful people sleep better (we all need that!)
6. Gratitude improves self-esteem
7. Gratitude increases mental strength.
Also, gratitude allows us to celebrate the present and blocks toxic and negative emotions. Grateful people are more stress resistant and have a higher sense of self-worth. I hope that you will take time during this season to find a moment of peace, to share special moment with family and friends and to be grateful for the good things in your life. Have a very safe holiday season and a happy and healthy New Year.
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PRESIDENT'S MESSAGE

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

The Society wishes you all a happy and healthy holiday season.  As we prepare for the New Year, as President of the Society, it is my goal to see us find ways to increase our outreach to all Arizona psychiatrists. As we strive to fight for parity, professional standing, scope of practice, and band together for educational, social, and collegial connection, increasing our strength in numbers is key to our efforts.  Consider inviting a psychiatric peer to attend our social event on January 30, 2016 (the Psychiatry Picnic at the Farm at South Mountain) or the Annual Scientific Meeting on April 30, 2016 ("Innovations in Psychiatry") at Marriott at The Buttes Resort, and I hope to see each of you there.    
ecialty Department Newslett
ARIZONA RFM DR. SALMON RUNNING FOR APA RFM TRUSTEE ELECT

Matt Salmon, DO, Arizona RFM
Candidate for APA RFM Trustee Elect
 
Dear Colleagues,

I am running for Resident-Fellow Member Trustee Elect on the Board of Trustees of the American Psychiatric Association, and aim to work with the APA building, bridges with our policy makers to bring about positive change within our community. It's 2015, but there still exists a stigma on mental health which leads to disparity for our patients' care and for our reimbursement. However, we also need to empower ourselves, increase membership and inspire advocacy from the ground up. Many have become disenfranchised resulting in subpar care from non-physicians, payer recalcitrance and impaired access to care.

This election is decided by Resident-Fellow Members of the APA. Many of you are not RFM, but can reach out to those you know. Encourage them to become an APA member and to vote in this election. Voting opens January 4, 2016 and ends February 1, 2016.

Matt R. Salmon, DO
APA FELLOWSHIP APPLICATIONS
DUE JANUARY 30, 2016

There are many Fellowship opportunities that current APA Resident-Fellow Members may apply for--and there is one common deadline:  January 30, 2016. VISIT http://psychiatry.org/residents-medical-students/residents/fellowships for more information about the many fellowship opportunities available to you. 
TREATING SUBSTANCE RELATED DISORDERS IN VETERANS 

Carlos J. Carrera MD DLFAPA
Specialty Psychiatry Section Chief - Phoenix VA HCS
Clinical Instructor Psychiatry - U of A COM-Phoenix

Disclaimer: The article represents the personal opinion and views of the author.  Factual references available from the author.
 
Only about 0.5%  (1.6M) of the American population (319M 2014) has been on active duty at any given time,
 
There are 22,658,000 veterans in America today, just 8 percent of which are female. (2011)
 
The Veterans Health Administration is America's largest integrated health care system with over 1,700 sites of care, serving 8.76 million Veterans each year.
 
Arizona has a total of 532,206 Veterans (10% are women). The VHA in Arizona has 3 Medical Centers (Prescott, Phoenix, Tucson), 19 Community Based Clinics (CBOCs) and 7 Vet Centers.
 
Approximately 18.5% of service members returning from Iraq or Afghanistan have post-traumatic stress disorder (PTSD) or depression, and 19.5% report experiencing a traumatic brain injury (TBI) during deployment.
 
Between 2004 and 2006, 7.1% of U.S. veterans met the criteria for a substance use disorder.
 
One in fifteen Veterans (6.6%) had a substance use disorder in 2013 whereas the national average was about 1 in 11 (8.6%.)
 
A recent Treatment Episode Data Set (TEDS) report states that about 70% of homeless veterans also experience a substance use disorder.
 
The rate of substance use disorders among veterans ranged from 3.7 percent among pre-Vietnam-era veterans to 12.7 percent among those who served in the military since September 2001
 
For alcohol, the prevalence range  has varied between 12-27 % with binge drinking in up to 53% in a sample of recently deployed personnel with combat exposure
 
For tobacco, a Committee on Smoking Cessation in Military and Veteran Populations, convened by the Institute of Medicine, found the rate of men and women who have tried tobacco in their lifetimes to be 74.2 percent in veterans and 48.4 percent in non-veterans
 
Stress served as the primary motivating factor for tobacco use during active duty (47.7%); 25.1% blamed boredom and 22.7% blamed addiction for their tobacco use.  A majority indicated an intention to stop smoking on returning from deployment but deployment is identified as a risk factor for ex-smokers to resume smoking.
 
Illicit drug use disorders are difficult to assess as illicit drug use during active duty may lead to (dishonorable) discharge. However, it is not uncommon in the Veteran population.
 
A survey of 28,546 active duty military members indicated that 11.1% reported misuse of prescription medications in 2008.
 
Prescription opioid pain medications can have effects similar to heroin when taken in doses or in ways other than prescribed, and research now suggests that abuse of these drugs may actually open the door to heroin abuse. (NIDA.) One in fifteen people who take non-medical prescription pain relievers will try heroin within ten years.
 
Not uncommonly, the Veteran that may have been legitimately treated and prescribed opioid pain medications may end up with an opioid use disorder.
 
The VHA is committed to addressing the opioid use epidemic among Veterans. At the Phoenix VA HCS, an office based clinic for the treatment of opioid use disorders using buprenorphine/naloxone was established in 2007. It was the first such clinic in VHA in Arizona.
 
The number of Veterans diagnosed, seen and treated has steadily increased in all fiscal years since 2008 from an initial 125 to over 450 Veterans.  If appropriate, inductions take place in a specialty setting and once maintenance phase is reached, the Veteran may be transferred to a waivered psychiatrist in general mental health. Capacity is greater than demand thanks to about 25% of the psychiatry staff being waivered. 

The VHA is also addressing the opioid epidemic with efforts to reduce opioid overdoses through education, training and distribution of naloxone rescue kits.
 
A recently established chronic non-cancer pain management program is helping address co-morbid pain and opioid addiction and identify Veterans at high risk.
 
Collaboration with specialty clinics also help address co-morbid substance use disorders and other conditions such as post-traumatic stress disorder, severe mental illness, traumatic brain injury,  hepatitis C and human immunodeficiency virus infections. Special populations for which services exist include combat Veterans, women,  homeless Veterans and  Veterans involved with the criminal justice system (at the Federal, State and County level.) There is increased recognition and attention to the families of Veterans as well.
 
Outpatient, residential and inpatient treatment services are available at all three main Arizona VHA medical facilities but each facility varies in what they offer. The recently passed CHOICE Act and Non-VA Care Coordination  allows Veterans to access services in the community as needed and indicated. The majority of Veterans do not come to VHA (for a variety of reasons; market penetration has been estimated at 30%) so community providers WILL see Veterans. Please ask your patients if they are Veterans, thank them for their service and keep VHA in mind. We are here to serve and help.
PLAN TO JOIN US:  SATURDAY, APRIL 30, 2016
ARIZONA PSYCHIATRIC SOCIETY ANNUAL MEETING
"Innovations in Psychiatry"
Marriott at The Buttes Resort 
APS Members are Free (Register To Hold Your Spot Today)
GET TO KNOW ONE ANOTHER:  
SATURDAY, JANUARY 30, 2016
Family Picnic Day - The Farm at South Mountain, 11 am to 3 pm, Picnic Lunch at 12 Noon
$100 Gift Card for drawing winner of Getting to Know You Bingo
Spouses and Children Invited!  Family drawing for youth activity as well.  OPEN FOR EARLY SIGN-UPS; REGISTER TODAY!


BRIDGES TO RECOVERY:
Understanding Addiction to Prescription Medication Triggered by Chronic Pain

Michael A. Sucher, MD, FASAM, FACEP
Chief Medical Officer
Community Bridges, Inc.
Medical Director, Monitored Aftercare Programs Arizona Medical Board, Arizona State Board of Dental Examiners, and State Bar of Arizona 

With permission of the author and consent of the publisher, the article "Bridges to Recovery: Understanding Addiction to Prescription Medical Triggered by Chronic Pain," originally published in Round-up Magazine, Volume 61, October 2015, is made available to our readers (click the Round-up Magazine link above).  

In addition, for a list of community resources available in Arizona, please visit http://communitybridgesaz.org/resource.
Bahoo Ghafoor, MS-IV
Dartmouth Medical School
New Psychoactive Substances (NPS) or "Designer Drugs"

Tariq Ghafoor, MD, Past President, Arizona Psychiatric Society, and
Bahoo Ghafoor, MS-IV, Dartmouth Medical School

At the mention of drug or substance abuse, most healthcare professionals think of cocaine, marijuana, PCP, heroin, and methamphetamine. However, there is an emerging trend and expanding market for "Designer Drugs" or New Psychoactive Substances (NPS). Often, these substances have chemical structures similar to traditional drugs of abuse yet different enough so as to be not picked up by traditional drug screens. Thus, there is a significant demand for these substances because they provide a "legal high". 

There are three main categories of NPS: Stimulants, Cannabinoids and Hallucinogens. 
 
Stimulants ("Bath Salts").....Synthetic Cathinones (Mephedrone, Methylone, MDPV).

The mechanism of action of these drugs is similar to amphetamines or cocaine.
Clinical effects include increased arousal, insomnia, euphoria, agitation, paranoia and hallucinosis, and serotonin syndrome. Manifestations of acute intoxication include agitated delirium, diaphoresis, tachycardia, hypertension, hyperthermia, metabolic acidosis, rhabdomyolysis, acute kidney injury, and seizures, violent behavior and can ultimately cause death. Symptoms of intoxication can last longer, up to weeks, than traditional stimulant drugs. Most UDS are not able to detect NPS and thus intoxication is a clinical diagnosis. The differential includes Acetaminophen and salicylate toxicity as well as anticholinergic poisoning and alcohol/benzodiazepine withdrawal. An ECG is recommended to detect arrhythmias and evaluate for cardiac ischemia from cathinone intoxication. CT scan is recommended in cases involving seizures, signs of head trauma and/or focal neurological findings.

Cannabinoids ("Spice", "K2") .....Napthoylindoles, Phenylacetylindoles, Cyclohexylphenol analogues, cannabicyclohexanol, UR-144, Oleamide

Although these drugs have been synthesized throughout the 1970's and 1980's they were popularized for abuse in early 2000's. These can be up to 100 times more potent than delta-9-THC. 

In addition to the symptoms of cannabis intoxication (conjunctival injection, xerostomia, etc), synthetic cannabinoids can cause hallucinations, delirium, dystonia, seizures, hyperthermia and psychosis. Sequelae of intoxication can include AKI and myocardial ischemia. In a review of 106 studies involving 4,000 cases, 26 deaths were attributed to this category of NPS. 

Like other NPS classes, symptoms can last much longer than the traditional drug. It is unclear whether the additional symptoms are a result of the synthetic cannabinoids or other compounds mixed with the synthetic cannabinoids. Laboratory testing is not indicated in mild intoxication although in severe intoxication (agitation, seizure and/or psychosis) a CBC, CMP, CPK and Urine Dipstick may be required. In suspected cases of synthetic cannabis intoxication it is important to rule out alcohol intoxication, mania, primary psychosis. As with other NPS drug screens are typically not helpful in diagnosis. Treatment of intoxication entails supportive care, judicious use of benzodiazepines and symptomatic treatment of neurologic and cardiac toxicity. 

Hallucinogenics ("N-bomb" or "Smiles") ...NBOMe

N-BOMe, commonly referred to as "N-bomb" or "Smiles," is a powerful synthetic hallucinogen sold as an alternative to LSD or mescaline (a hallucinogenic drug made from a cactus plant). There are several variations of this drug, but 25I-NBOMe, often shortened to "25I," is the most abused and potent form.

These NPS are structurally similar to mescaline (the hallucinogenic found in peyote). Signs of intoxication can include agitation, tachycardia, tachypnea, fever, mydriasis, delirium, hallucinations, myoclonus and seizures. Possible laboratory abnormalities can include elevated CPK, leukocytosis, hyperglycemia and transaminitis. NBOMes are potent activators of 5HT2a receptors and thus can result in serotonin syndrome. Symptomatology is highly variable as demonstrated by a case report in which 6 individuals ingested comparable amount on NBOMe and while 5 of these patients were managed with IVF and benzodiazepines and discharged relatively quickly, one patient experienced an agitated delirium and required ICU hospitalization for a week.

A common theme in abuse of these NPS is that users often expect the effects to be similar to traditional drugs in the same class. As noted above, however, these synthetic or designer drugs have far more variable effects and can in fact be life threatening even with one time use. Furthermore, the lack of laboratory testing to confirm the usage of NPS forces providers to rely on their clinical knowledge and experience when diagnosing and managing these cases in their day to day clinical practice.  
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Large crowd at the Committee of Reference (Sunrise) Hearing
LEGISLATIVE UPDATE: APRN Sunrise Application by Nurses Gets Out of Committee
Carol K. Olson, MD, FAPA
Legislative Chair

The following update was recently distributed by stand-alone e-mail due to its time sensitive nature and is repeated here for anyone who did not have a chance to review the same.

The Arizona Psychiatric Society, the Arizona Medical Association, the Arizona Osteopathic Medical Association, and other physician specialty groups, collaborated on over 4 hours of testimony at the state legislature on December 7, 2015 regarding a proposal by the Arizona Nurses' Association related to Advanced Practice Registered Nurses (Nurse Practitioners, Certified Nurse Midwives, Certified Registered Nurse Anesthetists and Certified Nurse Specialists). This complicated proposal included removal of requirements for collaboration with physicians, and would allow all of these advanced practice nurses to prescribe medications; in addition, it would allow certified nurse specialists in Psychiatry, but not other types of nurse specialists, to practice outside of a licensed healthcare facility or doctor's office.  It would also allow CRNAs to practice independently, removing the current requirement that they practice under the direction and control of a physician.
 
Unfortunately, despite strong testimony from physicians as to the inadvisability of granting these privileges to advanced practice nurses, in  part due to  the limitations of their training in matters related to prescribing, the measure passed the Sunrise Hearing on a 5-4 vote.  This means that the measure will be allowed to be considered by the legislature in the upcoming session.
 
The Legislative Committee and Executive Council of the APS are meeting now with our Lobbyist Joseph Abate to develop a strategy to oppose passage of this legislation, which we feel is not in the best interest of the citizens of Arizona and does not promote the high quality of medical care that all patients deserve.  If you are interested in participating in our lobbying efforts, please contact Teri Harnisch at APS (teri@azmed.org, 602-347-6903), and stay tuned for requests for further assistance such as personal communication with the legislators from your district regarding your opposition to this proposal.  

"My Turn, Calling for Comprehensive Mental Health Reform"
On December 7, 2015, The Arizona Republic published a guest editorial in their "My Turn" section, under the signature of Gurjot K. Marwah, MD, President-Elect of the Arizona Psychiatric Society, calling for comprehensive mental health reform and asking for collaborative efforts to make meaningful progress on the national stage on the mental health legislation that has been introduced recently.  CLICK HERE to read that guest editorial.
APA APPLAUDS COMPREHENSIVE JUSTICE AND MENTAL HEALTH ACT; APA ASKS MEMBERS TO ENGAGE TO OPPOSE PROPOSED DEFINITION OF PSYCHOLOGISTS AS "PHYSICIANS" UNDER MEDICARE
  • On Dec. 11th, APA applauded the senate passage of the "Comprehensive Justice and Mental Health Act," introduced by Senators Al Franken (D-Minn) and John Cornyn (R-Texas). The bill includes provisions that support APA's mission of reducing the number of people with serious mental illness in our nation's jails. You can read APA's statement of support for the bill here.
  • APA Members are encouraged to urge their member of Congress to protect patient safety in mental health treatment by opposing the Medicare Mental Health Access Act (H.R. 4277). The bill would define psychologists as "physicians" under Medicare, a designation that does not equate to the medical education residency training undergone by Medical Doctors. Click here  to encourage your Member of Congress to oppose the bill. 
ARIZONA ASSEMBLY REPS REPORT FROM APA FALL ASSEMBLY
Washington, DC, October 30-November 1, 2015

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

Dr. Gurjot Marwah and Dr. Payam Sadr both attended the APA Assembly in Washington, DC from October 30 to November 1, 2015. Following is a summary of the highlights of the APA Fall Assembly prepared by Dr. Gurjot Marwah: 

- Dr. Renee Binder, the president of the APA is passionate about her work on decriminalizing mental illness in the prison system. To this, on the second day of the Assembly, an important presentation was made by Dr. Paul Burton, the Chief Psychiatrist at San Quentin Prison in Northern California. The topic of his presentation was "Out of Sight, Out of Mind: The Mass Incarceration of American Mental Illness". He outlined the need for training law enforcement officials to be educated on how mental illness can present pre-incarceration. Jails are not good for anyone's mental illness. Often premorbid and new onset mental illness can present upon incarceration. Also he stressed rehabilitative treatment in the form of parenting groups, anger management, and drug rehab groups while in prison.

- An update was given about the upcoming APA Annual Meeting in Atlanta in May 2016.

- The APA presented the Profile of Courage award to former APA President and current President and CEO of Sheppard Pratt Health System, Steven S. Sharfstein, MD, for standing by the hypocratic oath of a physician to follow no harm. Under his astute leadership, the APA refused to participate in the interrogation of prisoners at Guantanamo Bay, unlike the American Psychological Association. 

- All Area Representatives are to encourage their state APA members to cast their votes in the upcoming APA elections. 

- Big issues were related to APA's stand about parity enforcement, encouraging members and patients to be whistleblowers about organizations and work places that to do not offer parity in mental health. The Speaker of the Assembly, Dr. Martin discussed scope of practice of psychiatry, specifically about psychologists wanting to prescribe. There is immense info with templates and tool kits that have been developed by the APA for use at the district branch levels for defending scope of practice. 

- CMS has given the APA a grant for 2.5 million dollars over 4 years to train 2500 psychiatrists all over the country in the collaborative care model.

-Tim Miller has been appointed as the new APA Regional Director that serves Arizona to support state legislative needs of those District Branches in the Southwest. 

It was enlightening to be part of the Assembly Action Paper process--over twenty Action Papers were considered during the Fall 2015 Assembly.  

Details regarding the Spring Area 7 Assembly Meeting are being finalized.  We are excited that the meeting is set to come to Scottsdale, Arizona on March 5-6, 2016.  
Gorillas in Rwanda are also affected by poaching
CECIL THE LION, AN AFRICAN PERSPECTIVE

Robin Reesal, MD
Psychiatrist in Rwanda
The death of Cecil the lion created a media storm. It is legal to hunt and kill lions in Zimbabwe, with suitable licenses. According to reports, Zimbabwe officials did not charge the tourist involved in the altercation. Millions of people are aware of Cecil's case and thousands of dollars have been raised for wildlife management. 

Information is poorly disseminated in many countries. Living in Rwanda, I learned about the death from U.S. reports, the "outside world". Why do some news stories "go viral" and others stay in the shadows? 
 
News is relative

Some facts about Africa are underreported. Over a thousand women are raped per day in the Democratic Republic of Congo. Worldwide, there is about one suicide every 40 seconds. Eastern Africa has one of the highest suicide rates in the world, 15 per 100,000. According to the United Nations, poor nutrition causes nearly half (45%) of deaths in children under five, 3.1 million children each year. About, 66 million primary school-age children attend classes hungry across the developing world, with 23 million in Africa alone. Zimbabwe, where Cecil was killed, has an intentional homicide rate about twice that of the United States, according to the World Bank, 2012.
For many people living in Africa, life is about survival. Most have limited access to electricity and communication systems. Given these realities, Africans were not as focused on Cecil's death. 
 
About lions

I came across an interesting article in South African Airways Sawubona (Zulu for "we see you" or hello) Magazine written by Chris Coetzee, September 2015 issue. The article is about the desert lion of Namibia and Dr. Philip Stander, a world authority on lions and founder of the Desert Lion Conservation Project. These lions are genetically similar to other African lions. These lions can go without water for up to six months. The savannah lions walk about 3-4 km per day (2.5 -3 miles per day) living in a range of 50 - 100 square km (19 - 38 square miles). By comparison, the desert lions walk about 12 -25 km per day (7.5 miles - 15 miles per day) living in a range of 10,000 - 30, 000 square kilometers (3,900 - 12,000 square miles)! Young females separate from their mother to live independently, an unusual pattern. The desert lion is an independent hunter by 18 months two years earlier than other lions. Lions kill about every three to sixteen days. They are active from 5 pm to 10 am with their greatest level of activity from about 4 am to 9 am. There are about 150 desert Kunene lions in Namibia.

Wildlife loss

Game hunters, local inhabitants protecting their livestock and those seeking financial gain, kill lions. Poaching of animals is a significant problem in Africa. According to the African Wildlife Foundation, up to 35,000 elephants were killed last year. Ivory is sold at 1,000 USD per pound. The ivory is used for art and utensils. The black rhino population has dropped by 97% since 1960. Rhino horns are worth about 30,000 USD per pound. Some believe they have medicinal value. There are fewer than 900 gorillas remaining. An infant gorilla is worth 40,000 USD on the black market.

Rwanda's success

Lions were hunted to extinction in Rwanda about 15 years ago. After the genocide in 1994 and 1995, returning refugees poisoned the lions to protect livestock, according to National Geographic. To the delight of many Rwandans, lions have been reintroduced to Akagera National Park this year. Now, Rwanda places importance on their safety.
Rwanda successfully runs a program in which they offer employment to former gorilla poachers and villagers around gorilla habitats. The local residents can work at a cultural village and as guides for gorilla tours. Having seen the gorillas in their natural habitat, I can say, great care is taken to assure their safety and preserve their lifestyle and environment. We visited the cultural village, chatted with a Rwandan natural healer and toured a traditional Royal House. Supporting the ancillary activities, helps prevent poaching. 

Guns and life 

The use of guns causes intentional and unintentional deaths of people and animals. The APA Headlines, October 9, 2015 issue, reported from the New York Times, "More Than 60% Of Americans Who Die From Guns Die By Suicide." Understandably, there is now a greater emphasis on separating the potential suicide victim from guns. In the same issue, taken from the Washington Post, "female veterans die by suicide at nearly six times the rate as those with no service record," because they use guns. World Health Organization statistics show from 2000 to 2013, around 6 million people died by acts of interpersonal violence, which is more than the deaths from all wars during that time. In a recent commentary entitled, Domestic Violence Awareness, AJP October 1, 2015 Issue, Anna Chapman and Catherine Monk state that intimate partner homicides make up 40% and 50% of all murders of American women. Decreasing access to lethal weapons is one solution for this disturbing problem. 
 
Closing thoughts

In my lifetime, the emphasis on news seems to have changed from being information based to entertainment. Financial gain, an opportunity for fame, a means of self-expression and a chance to promote a cause, may amplify a story. A prominent politician once said, "Pictures never lie, but they do not always tell the truth..."

The following quote from Joseph Conrad's Heart of Darkness, written in 1899, may capture the sentiments of those directly involved in Cecil's death.

"Droll thing life is -- that mysterious arrangement of merciless logic for a futile purpose. The most you can hope from it is some knowledge of yourself -- that comes too late -- a crop of inextinguishable regrets." 
RESIDENT-FELLOW MEMBER FALL MIXER

Jesse Reinking, DO
Resident-Fellow Member Co-Representative

On November 7, 2015, members of the Psychiatric Residency Programs from both Phoenix and Tucson gathered for a Fall Mixer at Riley's in Tucson, Arizona, immediately following the Eli W. Lane Memorial Master Workshop, which was attended by residents from both Phoenix and Tucson as well.  

Sean Tai, DO, Adam Ruggle, MD, and Aaron Dahl, MD, from University of Arizona, Banner Phoenix, and MIHS.
From Left counter-clockwise, Irfan Fauq, MD in front, Jesse Reinking, DO at end, Sean Tai, DO, Aris Mosley, MD, Aaron Dahl, MD, Jasleen Chhatwal, MD, and Jason Curry, DO


MULTIPLE SCLEROSIS FOR NON-NEUROLOGISTS

September 26, 2015
Cleveland Clinic - Lou Ruvo Center for Brain Health - Las Vegas, NV

A Report from Brian Espinoza, MD

I regularly attend this annual conference to try and keep up on the progress made by our neighbor, Neurology. It is usually a general overview of Neurology, but this year they decided to focus on a single disease. Highlights are as follows:

Multiple Sclerosis Overview
MS is the leading cause of non-traumatic disability in young adults.
Onset of disease is generally in the 20's thru 40's, however at the Cleveland Clinic, the disease has been identified as young as 2 years, and as old as 70 years.
In addition to the Neurologic manifestations of MS, depression and anxiety are Psychiatric symptoms that are often part of the overall clinical presentation.
In 1992, there were no treatments for MS. As of 2015, there are 12 FDA approved therapies, with 7 more currently being studied. The cost of drug therapy ranges from $50-65K/year.

Psychiatric Management of Patients with MS
Depression, anxiety, alcohol abuse, bipolar disorder and psychosis all have a higher prevalence rate in MS patients.
There is some initial research suggesting that the location and "load" of MS lesions dictate the psychiatric symptomatology, e.g. mania--ventral prefrontal.
MS + Depression = a lethal combination, resulting in 15% of deaths in MS, i.e. 1 in 6 patients.

(I queried the speaker on the safety of ECT in MS patients; he felt that it should not be problematic as long as lesion load was not producing a Mass Effect on Neuroimaging.)

Pain Management for the MS Patient
The take home message from this segment was to utilize opioids as a last resort, not a first, due to numerous complications.

Interpreting the Neuroimaging of the Multiple Sclerosis Patient
Neuroimaging has helped delineate that MS patients lose 0.5-1.4% of Brian Volume per year, compared to 0.3% in controls.

Cleveland Clinic is experimenting with a 7 Tesla Magnet MRI, more than double the standard magnet, which can show Periventicular Lesions in impressive resolution. It is not yet FDA approved, but may be in a couple of years.
Future developments include the refining of Quantitative Neuroimaging to elucidate Brain Volume changes, and white matter:gray matter ratios.

Keynote Presentation--Multiple Sclerosis and Women's Health
The female incidence of MS has tripled in the last half-century, and is continuing to increase.

Exposure to cigarette smoke, outdoor activity/sun-exposure, and Vitamin D show linkages to the development of MS.

The most common cause of death in female MS patients is stroke, with the mean age being 52 years old.

There definitely is an overlap of Multiple Sclerosis into the domain of Psychiatry. This CME was quite informative.
FIND-A-PSYCHIATRIST OPT-IN

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.