SUMMER NEWSLETTER
June 2016, Vol. 7, Issue 2
In This Issue



 
 






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From the Newsletter Editor-in-Chief

Mona Amini, MD, MBA

June 2016
L-R: Drs. Mona Amini and Shelley Uram at Women's Group Kick-Off Event at Meadows Behavioral Healthcare

Summer Greetings to our Readers:

This latest quarterly newsletter offers wonderful perspectives on the theme of Collaborative Care. As mental health integrates further within the medical landscape, psychiatric providers should anticipate working collectively more and more with our fellow medical colleagues.

I am grateful and fortunate enough to share photos from the first inaugural Arizona Psychiatric Society Women's Group event, held and sponsored by The Meadows Behavioral Health in Scottsdale, AZ in May. The event was a success largely because of the wonderful attendance of fellow female psychiatric colleagues, who shared some incredible career and life experiences. A heartfelt thank you to those who were able to join us that evening. We hope to organize our next event in the Fall (once the weather has hopefully cooled!).

Notably in every newsletter, highlights of the latest in legislation as well as APA Assembly reports are brought to our attention. This quarter we share such reports by APS Assembly Representatives Dr. Marwah and Dr. Sadr. APS Lobbyist Joseph Abate briefly discusses the recent legislation session that fortunately ended in restoration in Arizona of the KidsCare program.

Melissa A. Kotrys, CEO of AZ Health-e Connection, shares the goals of the new integrated health exchange of both physical and mental health data. Dawn Noggle, Mental Health Director for the Maricopa County Correctional Health Services, reports back from the Stepping Up Initiative held in Washington, DC, and shares the inspirational message of working together as a community to provide the appropriate treatment to the seriously mental ill rather than incarceration.  Dr. Robin Reesel shares his experience with collaborative care in Liberia, as well as personal experiences during his tenure in Rwanda. Dr. Brian Espinoza shares his experience during a recent conference workshop from the 2016 International Society of ECT and Neurostimulation where family-centered care in ECT is shown to have immensely positive feedback.

Lastly, we share a sad tribute to Dr. Max Dine who recently passed. Dr. Dine, though not a psychiatrist by trade, was most certainly a distinguished community liaison for mental health in Arizona. We thank Dr. Dine for his benevolence in advocating for the mental health community. 

P.S.: Please share your feedback and follow us on Twitter @AZPsychSociety or on Facebook through the group page "AZ Psychiatric Society."

More Photos From the Women's Group Kick-Off Event:

Drs. Shankar, Olson, Marwah, and Torio


Drs. Leet, Don, and MacDonald

Dr. Segal, Outgoing APS President, presents a Presidential Recognition Award to Dr. Gurjot Marwah at the APS Annual Meeting
PRESIDENT'S MESSAGE

Gurjot Marwah, MD
Arizona Psychiatric Society, President

In the year ahead, in service as the President of the Society, I look forward to advancing the goals of the Society as expressed in its mission statement:  "Promoting the welfare of those with mental illness and fostering principles of psychiatry."  I hope together we can invite a more collaborative approach among psychiatrists, developing connections that support members picking up the phone to consult a peer.

With thanks for the continued contributions of the Executive Council and the many leaders who make a difference, together we will continue to work to provide opportunities for member engagement, effectively advocate for mental health and mental health parity on the State and national level, support our members in their personal and professional activities (including recognizing their contributions), work to grow our membership, and plan a high quality Annual Meeting.  If you have ideas for an important educational topic and/or speaker for consideration, I welcome you to submit the same to the Society (teri@azmed.org).   
Devna Rastogi, MD
MEET FELLOW APS MEMBER: DEVNA RASTOGI, MD

Vice Chair, Department of Psychiatry, and Director of the Medical Student Clerkship, Maricopa Integrated Health Systems, Inc.; 2016 Recipient: Arizona Psychiatric Society Howard E. Wulsin Excellence in Education Award

Psychiatry was my first rotation of my 3rd year of Medical School at Washington University School of Medicine (WUMS) in St. Louis.   I immediately knew I had found what I wanted to do and told the Program Director.  He told me that "Everyone loves their first rotation of 3rd year.  Come back and see me if you are still interested at the end of the year."  Of course I did and then ended up doing my residency at WUMS and became faculty there after that. My first job was with the same hospital system that I first had contact with as a 3rd year medical student, taking care of the most impaired patients who often did not have insight into their illness and often needed court ordered treatment. I enjoyed taking care of patients in the public sector and working with a team model to do the best for the patients that we could. I found it very rewarding working with an entire team that brought different expertise to their approach.  The difference that we were able to make in the lives of our patients and families and providing what I felt was a service to the community, filled me with a lot of professional satisfaction. 
 
In addition to that, the role I had as a clinical educator gave me such a great amount of personal satisfaction that I wasn't expecting. My focus was teaching the WUMS Residents and medical students in our department who rotated through Metropolitan Psychiatric Center (MPC) the acute state facility that was associated with our program. I was able to work with top notch psychiatric residents and medical students who kept me challenged.  I received several teaching and mentoring awards, but gained as much from teaching those talented people as I gave.  Many of my former residents keep in touch with me and some are my closest friends and colleagues.  During my time at Washington University, I rose to the position of Associate Professor of Psychiatry at Washington University.  I was also the Assistant Clerkship Director for many years. 
 
In 2011 the teaching program at MPC closed due it being converted to a Forensic facility.  I chose to leave the department and move to Arizona mostly in search of better weather!  When I was looking for jobs, I was seeking a position as a clinical educator because I knew that was where I got the most fulfillment.  I wanted to continue to be able to have direct patient contact with the most impaired patients, while hopefully helping residents become better psychiatrists and helping medical students understand and appreciate how to take care of psychiatric patients no matter what specialty they chose. I was fortunate to find exactly what I was looking for at Desert Vista Behavioral Health Center. I joined District Medical Group and have a clinical appointment with the University of Arizona College of Medicine Phoenix as a Clinical Associate Professor of Psychiatry.

  
Dr. Rastogi presented with Howard E. Wulsin Excellence in Education Award at APS 2016 Annual Meeting by Dr. Aris Mosley
During the 5 years I have been at Desert Vista, I have been able to continue to work with excellent residents and medical students who inspire me. I was Associate Program Director for the MIHS Psychiatry Residency Program for almost 4 years and am currently Vice Chair of the Department and the Director of the Medical Student Clerkship. I have received another teaching award and was most honored being the recipient of the Howard E Wulsin Excellence in Teaching Award for 2016, nominated by my current Residents at MIHS.  My career is very rewarding.  What could be better than being able to contribute to the field of psychiatry by taking care of patients while knowing there are doctors throughout the country that I have helped in their approach to how to take care of this population of patients? Being a physician is an awesome responsibility. It has been my privilege to interact in my field with supervisors, colleagues, residents and students who have held me to a high standard and all helped shape the psychiatrist that I am. 

MEMBER NEWS FROM THE APA ANNUAL MEETING

Drs. Joel Parker, Cynthia Stonnington (photograph below), Monica Taylor-Desir, Karen Weihs, and Rodgers Wilson (photograph below) were recognized in the APA 2016 Convocation of Fellows as the newest Distinguished Fellows from the State of Arizona.   



L-R:  Dr. Cynthia Stonnington at the APA Convocation of Distinguished Fellows; Dr. Shabnam Sood is visited by Dr. Amadu Konteh during Dr. Sood's poster presenting at the APA Annual Meeting in Atlanta, Georgia; and Dr. Rodgers Wilson was also recognized as a 2016 APA Distinguished Fellow.

INTEGRATING PHYSICAL AND BEHAVIORAL HEALTH INFORMATION FOR BETTER PATIENT CARE 

Melissa A. Kotrys, Chief Executive Officer
Arizona Health-e Connection

Doctors and nurses have always been able to provide better care when they have more complete information on their patients. Never has more complete information been more important than today when health care providers face a future of value-based health care where payment is based on value and outcomes rather than the amount or type of services delivered. What's more, where more complete information is especially critical is in managing the health of the one in five adults with co-morbid physical and behavioral health conditions.

Arizona Health-e Connection (AzHeC) has taken a major step toward providing more complete patient information with the AzHeC Board's recent adoption of an approach and strategy for integrating physical and behavioral health data in the statewide health information exchange. This approach not only includes addressing state and federal laws regarding the exchange of physical and behavioral health data, but also the development of a unified communications and messaging strategy and a unified fee structure for both physical and behavioral health providers. The AzHeC Board eliminated Network participation fees for physical health providers as of October 2015, and now the elimination of participation fees has been extended to include community behavioral health providers.

The value of more complete patient information and the importance of securely sharing information among physical and behavioral health providers can be readily seen in a look at patients with the highest needs and costs. According to The Synthesis Report from the Robert Woods Johnson Foundation[1], about 5 percent of the adult population accounts for half of all health care spending nationally. A significant part of this high-need population are the 34 million adults or 17 percent of the adult population that have co-morbid mental and medical conditions. In fact, numerous studies have found that co-morbidity between medical and mental conditions is the rule rather than the exception. For example, people with diabetes or chronic asthma self-report depression at two to three times the rate of the general population, and persons with cardiovascular disease are at an elevated risk of having a lifetime anxiety disorder.

A key to providing integrated exchange of physical and behavioral health data is the ability to manage the state and federal laws that govern these two types of data. There are three basic sets of laws that apply: the Health Insurance Portability and Accountability Act (HIPAA), the federal substance abuse treatment privacy laws (42 CFR Part 2 in the Code of Federal Regulations), and Arizona's health information organization (HIO) law. AzHeC's integrated HIE strategy employs a hybrid approach that meets all state and federal legal requirements for patient notification and consent while affording all patient rights under the laws.

The Network currently manages physical health data according to Arizona's HIO law which provides patients notice of their right to opt-out of having their information shared. If patients do not opt out, authorized providers are able to access the physical health information of their patients. Under the integrated plan, behavioral health data is under "restricted access" which means that in order to comply with 42 CFR  Part 2, a provider can request patient consent to access restricted data and then access the data with affirmative patient consent. In addition, as long as a patient has not opted-out of having their information shared, emergency access to restricted data is available by a provider electronically affirming that an emergency is taking place. The Network's current technology vendor has the capability to restrict access to certain types of information, so no new technology will be required to operate this new strategy.
Closely related to the roll-out of AzHeC's statewide integrated HIE strategy, AzHeC has recently collaborated with Mercy Maricopa Integrated Care, the regional behavioral health authority (RBHA) for Maricopa County, to implement a Network crisis portal to support the behavioral health crisis countywide. It is anticipated that this crisis portal will be extended to RBHAs in the northern and southern areas of the state later this year.

The elimination of participation fees for community providers has resulted in strong growth in Network participation, and adding community behavioral health providers to the list of those with no participation fees will spur even stronger growth. Since launching its new technology platform in April of 2015, The Network has grown from 33 participants to more than 100 participants by the second quarter of 2016, and many of the newest participants are behavioral health organizations that have recently joined The Network.

As with other initiatives throughout our history, AzHeC relied on broad community outreach and engagement to develop a statewide strategy. Much of the information gathered over a period of several months helped to inform and design the plan and its implementation. In the end, not only was there broad community support for one statewide integrated health information exchange for physical and behavioral health information, there was also a consensus in the community that one system would provide the best care and the best outcomes for Arizona patients.


[1] "Mental disorders and comorbidity," Goodell, S, Druss BG, Walker, ER, The Synthesis Project (Policy Brief No. 21), Robert Woods Johnson Foundation, February 2011.
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AWARD RECIPIENTS FROM THE APS ANNUAL MEETING


Dr. Roland Segal, APS President 2015-2016, presented the following at the APS Annual Meeting, clockwise from upper left: Outstanding Resident Recognition Awards to Dr. Jesse Reinking, University of Arizona College of Medicine, Dr. Alicia Cowdrey, MIHS, and Dr. Matthew Markis, Banner UofA COM, Phoenix; Presidential Recognition Awards to Dr. Mona Amini and Dr. Aaron Wilson.  Bottom right: Dr. Payam Sadr, APA Assembly Representative, presented the Career Achievement Award in Psychiatry to Dr. Martin Kassell.  (Award recipients featured in photographs above, Dr. Devna Rastogi, Howard E. Wulsin Excellence in Education Award, and Dr. Gurjot Marwah, Presidential Recognition Award.)  

Dr. Jack Potts (center) presented the Excellence in Forensic Psychiatry and Community Advocacy Award by Step Up Arizona (photographed here with Executive Directors of NAMI Arizona (Jim Dunn) and David's Hope (Mary Lou Brncik) 
Stepping UP: A Movement Not a Moment!

Dawn Noggle, PhD
Mental Health Director
Maricopa County Correctional Health Services

In April, Maricopa County was one of 50 jurisdictions selected to attend the Washington, DC National Stepping Up Summit. This watershed event was sponsored by the Council of State Governments, National Association of Counties, and notably, the American Psychiatric Association Foundation. The Initiative was born out of years of frustrating, heartbreaking, and increasing movement of seriously mentally ill individuals into the criminal justice system, often with devastating impact, and a trajectory of further justice system involvement. Each year, 2 million people with mental illness are booked into jail or prison. National statistics show that there are more people in jails and prisons with mental illness (three to six time higher than the general public) and that most of these individuals are not a public safety risk. In 44 states, jails and prisons are the largest housing institutions for individuals with mental illness. Practitioners in our community are well aware of the connection between the lack of an adequate and affordable continuum of housing and treatment services and the growing, undertreated problem of substance abuse. 
 
The Stepping Up Initiative aims to rally national, state, and local leaders around the goal to reduce criminal justice involvement, especially jail and prison time, for individuals dealing with serious mental illness and substance abuse disorders. The strong advocacy of the American Psychiatric Association and the local Arizona Psychiatric Association is critical. We all recognize that solutions require criminal justice partners at all levels, the behavioral health system and housing providers. One "system" cannot solve this problem. The Stepping Up Initiative was launched in May 2015. Over the past year, over 250 counties have adopted resolutions to support the Stepping Up goals. 
 
 
Highly Recommended Reference: Group for the Advancement of Psychiatry (GAP) publication: People with Mental Illness in the Criminal Justice System: Answering a Cry for Help (2016) APA Publishing
Maricopa County being an early adopter, enacted a Stepping Up Proclamation in May 2015. This Proclamation was aligned with County Board of Supervisors adopted goals from 2014 to reduce recidivism of the seriously mentally ill in our jails. Many jails cite as many as 25 - 30% of their population having seriously mental disorders. In 2015 Maricopa County jails, individuals with an SMI designation accounted for 5% of the population, with approximately 7-7.5% at any point in time. Adding individuals who struggle with serious mental health issues (not SMI designated) brings the total population to approximately 20%. We know that our relative success has the following contributors: Crisis Intervention Trained officers; a robust Psychiatric Urgent Care Center with "no wrong door," early identification and continuity of care for individuals upon booking into jail, and collaborative work with the Mercy Maricopa Integrated Care system of community agencies to create better community transition plans.

We cannot celebrate. Not yet. The work before all of us is tremendous. We must advance the Stepping Up Initiatives while we have the public and policy makers' attention. This means action from the community psychiatric providers to jail/prison based providers. We have to standardize our risk assessments and psychiatric evaluations and include taking a criminal justice history; we have to treat criminogenic risk factors beyond psychiatric disorders; we have to advocate for the right services and right "dosage" for individuals upon release into the community. And, we have to collaborate; we have to share information. Stepping Up cannot be a moment, it has to be a movement.  To learn more about the Stepping Up Initiative, or to take the personal pledge, visit https://stepuptogether.org/ 


On June 9 and 10th, David's Hope - Arizona Mental Health Criminal Justice Coalition held a local mental health criminal justice summit at the Mesa Convention Center, in furtherance of the national goals of the Stepping Up Initiative.  The event was very well attended by behavioral health and correctional and first responder representatives from across the State of Arizona.  The Step Up Arizona Summit also honored over a dozen law enforcement officers and first responders for their efforts above and beyond in promoting the appropriate treatment of mentally ill, together with an award (photographed above) recognizing Dr. Jack Potts, Past President of the Arizona Psychiatric Society, and member of the Legislative and Forensic Committees, for his work providing treatment to and advocating for the seriously mentally ill.  
Max Dine, MD
REMEMBERING MAX DINE, MD
Arizona Psychiatric Society
Community Liaison Representative
Board of Directors, Mental Health America of Arizona


In memory of APS Community Liaison Representative and long-time behavioral health advocate, Max Dine, MD, we share with you the following tribute from the Newsletter of Mental Health America of Arizona (Also in Dr. Dine's spirit and in tribute to him, we share the link from MHA-AZ to its Mental Health Awareness Month educational and awareness resource).  For more information about MHA-AZ or to subscribe to its Newsletter, visit http://www.mhaarizona.org/.  Dr. Dine's obituary can also be viewed here.

Thank you Max Dine

We recently said goodbye to a tremendous mental health advocate, Max Dine. Cheryl Collier, President of the Mental Health Guild and past Executive Director of MHA-AZ, reflects a little on who Max was. Max was "a wonder - a one in a million." After moving to Arizona from Colorado, Max joined MHA-AZ's board and within a short period of time he "became one of the greatest & best known advocates in Arizona." Max Dine was selected as a recipient of the MHA Clifford Beers award, which is the most honorable award given out by our national affiliate. "Max won hearts and changed minds. He became very dear to all of us." On behalf of MHA-AZ and this large mental health community, we want to thank Max for all he has done. Our thoughts and prayers are with his family and all who knew and loved him.  
APS Lobbyist updates the attendees at the Advocacy Reception on April 29, 2016 sponsored by American Professional Agency, Inc.
HEALTH LEGISLATION REPORT

Joseph F. Abate, Esq.
APS Lobbyist

The Fifty-Second Legislature, Second Regular Session (2016) ended with a cliffhanger resolved in the restoration of KidsCare.  Interestingly, two bills were vetoed by the Governor, S1443 Regulatory Boards (Regulatory Board issues were debated at length in this session, including H2501, which was diluted down so much in the process it did not get through the Senate, and this issue will return next session) and H2510 Nonrestorable Defendants (H2704, among many other things detailed in the full bill summaries, authorized a study on this issue).  
 
CLICK HERE for the full bill summaries for the legislation enacted relating to behavioral health enacted in this session.  Abbreviated descriptions of the most impactful new laws are as follows (click above for the full descriptions):

H2310:  BIOLOGICAL PRODUCTS; PRESCRIPTION ORDERS.  A pharmacist is permitted to substitute a biological product for a prescribed biological product only if a list of specified conditions is met, including that the U.S. Food and Drug Administration has determined the substituted product to be an "interchangeable biological product" (defined) and that the prescribing physician does not designate that substitution is prohibited.  Effective January 1, 2017.
H2442: BEHAVIORAL HEALTH; URGENT NEED; CHILDREN.  Provides detailed steps and required support when an out-of-home placement or an adoptive parent of an eligible child identifies an urgent need for the child to receive behavioral health services.  
H2502: MEDICAL LICENSURE COMPACT.  Enacts the Interstate Medical Licensure Compact to establish a comprehensive and streamlined process allowing physicians to become licensed in multiple states.
H2599: AHCCCS; PROVIDER PARTICIPATION; EXCLUSIONS.  The AHCCCS Administration is required to "exclude" (defined) from participation in AHCCCS any individual or entity that meets any basis for mandatory exclusion described in federal law. The AHCCCS Administration, in its sole discretion, is permitted to exclude from participation in AHCCCS any individual or entity that has met any basis for permissive exclusion described in federal law or committed a list of prohibited acts. Does not exclude any other basis for exclusion as determined by the AHCCCS Administration. Severability clause.
H2704: BUDGET; BRB; HEALTH; FY2106-17.  Makes various policy changes in the area of public health that affect the budget. 
H2705: BUDGET; BRB; HUMAN SERVICES; FY2016-17.  Makes various policy changes in the areas of human services that affect the budget.  
S1169: MENTAL HEALTH POWER OF ATTORNEY.  Various changes to statutes relating to mental health care power of attorney. The physician that determines that a person lacks the ability to give informed consent may be a specialist in neurology, in addition to psychiatry or psychology. 
S1283: CONTROLLED SUBSTANCES PRESCRIPTION MONITORING  PROGRAM.  Beginning the later of October 1, 2017, or 60 days after the statewide health information exchange has integrated  the Controlled Substances Prescription Monitoring Program data in the exchange, a medical practitioner, before prescribing an opioid analgesic or benzodiazepine controlled substance listed in schedule II, III or IV for a patient, is required  to obtain a patient  utilization report regarding  the patient  for the preceding 12 months  from the Program's central database tracking system at the beginning of each new course of treatment  and at least quarterly while that prescription remains a part of the treatment.  Some exceptions. 
S1363: INSURANCE COVERAGE; TELEMEDICINE.  Health and disability insurance policies or contracts executed or renewed on or after January 1, 2018  are required to provide coverage for health care services for trauma,  burn, cardiology, infectious diseases, mental health disorders, neurologic  diseases, dermatology  and pulmonology that  are provided through "telemedicine" (defined as the use of interactive audio, video or other electronic media for diagnosis, consultation or treatment) if the service would be covered were it provided through in-person consultation and if the service is provided to a subscriber receiving the service in Arizona, instead of only in a rural region of Arizona. Does not apply to limited benefit coverage.  Effective January 1, 2018.
S1442: MENTAL HEALTH SERVICES; INFO DISCLOSURE.  Requirements for a health care provider  or entity  to disclose confidential health care  records  are  modified  to allow the disclosure to relatives/ close personal friends or any other person identified  by the patient as otherwise authorized  or required  by state or federal law. 
S1457: KIDSCARE ENROLLMENT; EMPOWERMENT SCHOLARSHIPS; DISABILITIES.  Total enrollment in the state Children's Health Insurance Program (KidsCare) is no longer limited based on the annual appropriations made by the legislature and an enrollment cap. 

If you would like any additional information, please contact the APS Lobbyist, Joe Abate, at 602-380-8337.  If you are interested in being a part of the Legislative Committee of APS, chaired by Dr. Roland Segal, please contact teri@azmed.org
ARIZONA ASSEMBLY REPS REPORT FROM APA ANNUAL MEETING
Atlanta, Georgia, May 2016

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

Dr. Gurjot Marwah attended the APA Assembly Sessions preceding the APA Annual Meeting in Atlanta, Georgia.  Speaker Dr. Glenn Martin presided over what he foretold would be an Assembly replete with lively and intense discussion, including the deliberation of no less than 32 Action Papers, 19 Position Statements, 4 changes to the Assembly Procedure Code, 1 Change to APA Bylaws, and 2 additional Action Papers introduced as new business, for a total of 58 items on the Agenda.  

Among the more notable Actions taken by the Assembly during this session:
* The Assembly voted to have APA develop Positions Statements on
o Mental Health Hotlines
o Migrant and Refugee Crises Around the World
o Psychiatrists should not deliberately prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.
o A Psychiatric Response to Human Trafficking (approved by Consent).
* In addition, The Assembly voted to reaffirm position statements on "Detained Immigrants with Mental Illness" and "Xenophobia, Immigration, and Mental Health" and support access to Mental Health Services for families and children seeking asylum.
* The Assembly voted to support developing a Practice Guideline for Inpatient Psychiatric Treatment
* Access to Care received considerable attention, as the Assembly voted to support
o Third Party coverage of Medications Found to be beneficial to an individual patient
o Eliminating Out of Pocket Cost Barriers to care for patients with serious mental disorders
* The Assembly voted to have the APA develop a certificate program to satisfy the PIP requirement for Maintenance of Certification and for federal reimbursement, when needed.
* The Assembly voted to support the reintroduction of a previous Action Paper Opposing Direct to Consumer Advertising.
o In addition, because the previous iteration was not endorsed by the JRC, the Assembly voted to refer the paper directly to the APA Board of Trustees.
* The Assembly voted to improve PDMPs (Prescription Drug Monitoring Programs by including methadone and buprenorphine prescriptions.
* The Assembly voted to Protect Senior Psychiatrists from mandatory competency testing, based solely on age.
* The Assembly voted to support developing a resource document to provide ethical guidance on if and when it is appropriate to use patient information from targeted internet/social media searches.
    
CLICK HERE for the full APA Assembly Notes, including additional reports and updates on efforts and goals of the APA.
PRACTICE OPPORTUNITIES FROM OUR MEMBERS 

Private Practice Opportunity (Phoenix)

Established outpatient psychiatric practice seeks full-time or part-time psychiatrist. Referral resources well established; scheduling, billing, and collection systems are in place and fully functional.  On-site nurse provides liaison between psychiatrist and clinical patients, and oversees medication refills.  
For questions, contact:  Joel Parker, MD, 602-843-0035, or  joelparker@icloud.com.  


Private Practice Opportunity (Tucson)

Take over patient care and office space of retiring psychiatrist in Tucson Medical Park, by Tucson Medical Center in East Tucson.  Join over-head sharing arrangement for all office services, with established providers: Psychiatrists - Dennis C. Westin, M.D. and Adriana Boiangiu M.D.; Psychologist - Wayne Satten Psy.D.; and Therapist - Julie Westin MSC, LPC.  For more information call 520-795-0309.  
ARMA HOUSE OF DELEGATES REPORT  
Dr. Gretchen Alexander, delivering her inaugural address at the Arizona Medical Association President's Banquet


Brian Espinoza, MD
Roland Segal, MD, FAPA
June 3-4, 2016

Roland Segal, MD, FAPA, and I served as APS Delegates to the ArMA Annual Meeting House of Delegates held on June 4, 2016. Psychiatry was well represented with the newly inaugurated ArMA President, Gretchen Alexander, MD, at the helm, and Lee Ann Kelley, MD, serving as a delegate from the Maricopa County Medical Society.

Some interesting topics discussed and amended included:

Letting medical schools determine clinical skills competency as opposed to the current mandated USMLE examinations, which are time-consuming and a financial hardship to medical students.

It was voted not to support a salary cap on Physician Executive Pay. This was legislation introduced by the public and opposed by the Chamber of Commerce.

An End of Life Task Force has been created to help advise Legislators on upcoming issues in this area.

It was voted that ArMA not take an official position on legalizing marijuana for recreational purposes. This position would allow ArMA to remain more engaged with Legislators as issues develop on this topic.

The icing on the cake, which has been reported in The Arizona Republic, and through various other regional media outlets, was refining the language of ArMA's public statement of No Confidence in the current leadership of the University of Arizona College of Medicine - Phoenix after the entire Deans' Administration resigned.

Overall, another productive House of Delegates meeting in the best interest of the patients we serve.

CME AND EVENTS:  FREE APA TRAININGS: MACRA WEBINAR, INTEGRATED TRAINING, COURSE OF THE MONTH: PERSONALITY DISORDERS; MAYO CLINIC COMMUNITY GRAND ROUNDS; GERIATRIC SUMMER CONFERENCE; CALIFORNIA PRIMARY CARE INITIATIVE

 The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) permanently repealed the old Medicare SGR formula and set in motion entirely new programs for quality reporting and new payment models. What will this mean for your practice? On Wednesday, June 29, from noon to 1 p.m., APA will host a live, free webinar to educate you about several key features of MACRA. CLICK HERE to register for this event.

Each month APA makes available a free CME course exclusive to members only through its Learning Center. June's selection is "Advances in Psychodynamic Psychiatry: The Classification of Personality Disorders: New Developments." CLICK HERE for more information.


As part of the Transforming Clinical Practice Initiative (TCPI), APA will offer training to psychiatrists to support practice transformation through nationwide, collaborative, and peer-based learning networks. 
 
Free training is available to psychiatrists through online modules and live trainings.  CME credit is also offered. Content is similar for both training sessions so you may choose to participate in one or the other based on your learning preferences and availability.  
    
Online Modules - CLICK HERE to get started! There are two parts to the training containing seven modules in all. It is recommended that participants complete both parts 1 and 2.  For a flyer to share with peers, whether member or non-member, CLICK HERE.
 
LIVE INTEGRATED CARE TRAINING IN ARIZONA:  SAVE THE DATE - AUGUST 27, 2016.  MORE INFORMATION TO FOLLOW ON LIVE COLLABORATIVE CARE TRAINING FEATURING APA NATIONAL SPEAKER AND LOCAL TCPI PARTNERS.  FREE TO APA MEMBERS AND NON-MEMBERS.


Mayo Clinic Community Grand Rounds, "Emerging Technology for Telemental Health," presented by Eric Greenman, MD, on Monday, July 25, 2016, Room CP 34A/B, Concourse Level, Scottsdale Campus, 13400 East Shea Boulevard, Scottsdale, with socializing and lunch (brown bag) from 11:30 to 12:00 Noon, and presentation from 12:00 Noon to 1:00 pm.  If attending, please RSVP by e-mail to Gloria Mike.  For the full flyer, CLICK HERE.  

Arizona Geriatrics Society 2016 Summer Conference, "Self-Care for the Health Professional: Practicing What We Teach," Friday, July 29, 2016, Black Canyon Conference Center, 9440 N. 25th Avenue, Phoenix, Arizona.  Register Online or View the Flyer for more information.  

Essentials of Primary Care Psychiatry 2016 Conference, Friday, August 19th to Saturday, August 20th, 2016 At the Renaissance Long Beach Hotel, Long Beach, CA, Jointly Provided by the California Psychiatric Association and the University of California, Irvine School of Medicine.  This activity is approved for AMA PRA Category 1 Credits TM.  Physicians may claim up to 14.25 credits in the activity and other Mental Health Professionals may inquire about credits for their specialties.
* Registrants receive Lippincott's Primary Care Psychiatry Textbook included with registration!
* Practical "primary care psychiatry" clinical pointers for primary care providers and mental health providers
* Important DSM-5 diagnostic updates
* Topics include: Mood/anxiety disorders, substance misuse, personality disorders, collaborative care, pain psychiatric management and how to do a primary care psychiatric interview
* Hear from speakers who are national experts in the practice of psychiatry in the non-psychiatric setting
* Small group discussion and personalized learning with faculty who practice in both primary care and psychiatric settings
* UCI Certificate of Completion for each attendee.

VIEW THE BROCHURE OR VISIT ONLINE REGISTRATION HERE.  Send in the registration page via fax 916-442-6515 or via email to Lila-schmall@calpsych.org Or contact Lila Schmall at 800-772-4271.

SUPPORT AND INFORMATION FOR SCHIZOPHENIA, SCHIZOAFFECTIVE, AND BIPOLAR DISORDER

Choices in Recovery/Mental Health Resources is an online resource with support information for schizophrenia, schizoaffective, and bipolar disorder patients.

The resources are there to help individuals be informed, participate, and take action.

Discover worksheets, workbooks, decision aids, multicultural resources, and helpful organizations. These tools can help your patients get involved in their own mental health recovery journey, make medication and treatment decisions, and work toward personal goals.

The mental health resources are helpful to the individual and members of his or her treatment team or support network. For additional updates, patients or caregivers can subscribe to the free Choices in Recovery Newsletter. 

ALL PSYCHIATRIC RESIDENCY PROGRAMS REPRESENTED AT THE RFM MIXER

Thanks to the planning efforts of Dr. Aris Mosley, Dr. Wanda Shao, Dr. Jesse Reinking, and Dr. Brandon Yates, Resident-Fellow Members from all Arizona psychiatric residency programs gathered together at Top of the Rock at the Buttes immediately following the conclusion of the APS Annual Meeting.  
  

(L-R) Top left: Dr. Matt Markis and wife, Dr. Wanda Shao, and Dr. Adam Ruggle; Top right: Dr. Alicia Cowdrey, Dr. Kit Gesmundo, and Dr. Brandon Yates; Bottom Left: RFMs gather, Center: Dr. Aris Mosley and Dr. Nancy Yan, Bottom right: Dr. Shehzad Ayub, wife of Brad Zehring, Dr. Brad Zehring, Dr. David Chong, his wife, and Dr. Wanda Shao.  
REPORT FROM 26th ANNUAL INTERNATIONAL SOCIETY FOR ECT AND NEUROSTIMULATION (ISEN)

May 15, 2016
Atlanta, Georgia

Brian Espinoza MD
Interventional Psychiatry

ISEN continues to grow and had the largest turn out ever this year.  The morning was spent with presentations on the topic of preventing relapse after an initial series of ECT or TMS (Maintaining Remission Following ECT for Depression: Psychopharmacological Approaches, Ultra Brief Pulse Right Unilateral ECT, Maintenance ECT for Patients with Clozaril-Resistant Schizophrenia, Long-Term Outcomes with TMS Therapy, and THM).  

The afternoon was spent in breakout Workshops and Abstract Presentations (my reporting is from Novel Brain Stimulation-Update on Neuromodulation Treatments Update on t-DCS  (transcranial Direct Current Stimulation), Update on DBS (Deep Brian Stimulation), Update on MST (Magnetic Seizure Therapy), and 
Family-Centered Care in ECT, which was a leading topic of the Conference, introduced at the more formal Morning Session).  

For a detailed report, CLICK HERE.  I am currently in the process of bringing Family-Centered ECT to our current service at Aurora Behavioral Health Hospital in Glendale, and, the soon to be opened ECT service at Aurora Tempe.  If I can be of any help in ferreting out the above, please contact me at BrianEspinozaMD@gmail.com.
COLLABORATIVE CARE: AN INTERNATIONAL PERSPECTIVE

Collaborative Care an International Perspective
June 2016
Robin T. Reesal MD, Psychiatrist in Liberia

This article offers an international perspective on the integration of mental health into primary care to address global needs.  Mental health conditions are expected to cost the global GDP 16.1 trillion USD over 20 years according to World Economic Forum in 2011. (1)

The United States approach to integration
 
The American Psychiatric Association and the Academy of Psychosomatic Medicine jointly produced a 2016 report title, Dissemination of Integrated Care Within Adult Primary Care Settings. (2) This report argues, based on three decades of evidence, the Collaborative Care Model is the best model for integrating mental health services at a primary care level in the United States.  Based on expert consensus the Collaborative Care Model should be team-driven, population focused, measurement guided and evidence based. The report states a multidisciplinary team provides "treat to target" clinical goals for each patient within a given population. This approach serves each patient within a defined system.

The World Health Organization (WHO) and World Organization of Family Doctors (Wonca)* approach to integration

The WHO and Wonca in their 2008 document titled Integrating Mental Health Into Primary Care, offers a less restrictive view of integrating mental health into primary care. "There can be no single best practice model that can be followed by all countries. Rather successes have been achieved through sensible local application of broad principles." (3)

The international perspective emphasizes the whole person. Dr. Margaret Chan, the Director General of the WHO has written, "integrating mental health into primary care facilitates person-centred and holistic services..."(3) The WHO emphasis on molding integrative care around the patient is grounded, in part, by the 1978 Alma-Ata Declaration.(4)

The Alma-Ata Declaration was created from the International Conference on Primary Health Care in Alma-Ata USSR. Some consider it a major milestone in public health. The Declaration asserts that health is "a state of complete physical, mental and social wellbeing and not merely the absence of infirmity." (4)

Limited resources

The WHO estimates that in low and middle-income cou
ntries, between 76% and 85% of people with severe mental disorders receive no treatment. In high-income countries, between 35% and 50% of people with mental disorders are in a similar situation. (5) Low income and middle-income countries spend less than 2 USD per year per person on treatment and prevention of mental health conditions with a large part of this going to inpatient care. Upper income countries spend 50 USD per year per person. (6)

The median number of mental health care workers is 9 per 100,000. This number varies from less than 1 per 100,000 in low-income countries to 50 per 100,000 in high-income countries. (6)

Mental health services in resource poor countries often focus on a single institution, which have been associated with poor outcomes and human rights violations. (7) Less than 25% of countries provide community based comprehensive integrated mental health care. (6)

Mental health treatment can be cost effective

The authors of a recent Lancet Psychiatry article found that treatment of depression and anxiety disorders could lead to increased economic productivity gains of 230 billion USD for depression and 169 billion USD for anxiety disorders. (8)

My experiences

In Rwanda there was a major psychiatric hospital known to locals as "kilometer fifteen". The mileage from the capital, Kigali, became the identifier for the institution. In Monrovia, Liberia where I recently arrived, there is a similar but smaller mental health hospital, which I have yet to visit. In Rwanda, there were fewer than ten psychiatrist for over eleven million people. They were city based. In Liberia, there is one psychiatrist to service over four million people. He is city based.  
Because of limited and varied resources, I can see why the WHO has a wider scope solution for integrating mental health into primary care. Being in post Ebola Liberia, surrounded by a devastated health system, what is the best model to deliver mental health services? The collaborative care model is based on a different resource base. Would it apply to Liberia? Probably, but how generalizable is research from a high-income country to a resource poor country? Flexibility and pragmatism wrapped around known evidence may be the best approach.

An African clinical case

An African father and business owner in his thirties underwent numerous investigations at home and in Europe by multiple specialists over one year. He had a host of subjective and diverse physical symptoms. Before the primary care doctor's referral, he was told he had no major medical condition. One of the medical specialists prescribed alprazolam. He continued to suffer and had no explanation for his symptoms. After being evaluated and discussing the relationship of physical symptoms to anxiety and stress, he showed about a fifty percent improvement. He realized he was not going to die. He was not cursed. He would be able to watch his son grow up. He did not need an urgent plan for a family member take over his business. An integrated approach at a primary care level may have saved money, time, and suffering.

Closing thoughts

High-income areas such Australia, Canada and European countries are shifting towards integrative care models for mental health delivery. (9) (10) (11). The WHO in its global approach is moving towards integrative care, as stated in its Mental Health Action Plan 2013 - 2030. (7)

In my view, integrative care is about the art and science of healthcare delivery using a biopsychosocial model with an emphasis on the person versus their condition. Decades ago the famous international physician, William Osler said, "The good physician treats the disease; the great physician treats the patient who has the disease." (12) I think this approach is being reconfigured for a modern health care system.

*Wonca = first five initials of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians

FOOTNOTES:
 
(1)  
http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunica
bleDiseases_2011.pdf 
(2) https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/collaborative-care-model 
(3) http://www.who.int/mental_health/resources/mentalhealth_PHC_2008.pdf
(4) http://www.who.int/publications/almaata_declaration_en.pdf
(5) http://www.who.int/mediacentre/factsheets/fs396/en/
(6) http://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2014/en/
(7) http://www.who.int/mental_health/action_plan_2013/en/
(8) http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(16)30024-4/fulltext
(9) http://www.phcris.org.au/publications/policyreviews/issues/mhs.php
(10) http://www.cfpc.ca/uploadedFiles/Collaborative%20mental%20health%20care-2011-49-web-FIN-EN.pdf
(11) http://www.euro.who.int/__data/assets/pdf_file/0019/251434/What-is-the-evidence-on-the-economic-impacts-of-integrated-care.pdf
(12) http://www.brainyquote.com/quotes/authors/w/william_osler.html

PARITY POSTER UPDATED FOR ARIZONA

 
An updated version of the poster created by the American Psychiatric Association and the Arizona Psychiatric Society to support parity enforcement, "Fair Insurance Coverage: It's the Law," is available here for download (with both English and Spanish translation) and is posted at http://azpsych.org