December 2016-January 2017, Vol. 7, Issue 4
In This Issue


Premium Corporate Sponsor 2016-2017

From the Newsletter Editor-in-Chief

Mona Amini, MD, FAPA, MBA

Dear Psychiatric Colleagues:

Happy New Year to you all! 

2017 has rapidly begun, and we at the Arizona Psychiatric Society are happy to share in the excitement of new beginnings. 2016 brought new members and new Arizona residents to our Society, the initiation of our new Psychiatric Women's Group, new initiatives from our Legislation, continued advocacy from the Society and the APS Lobbyist, a family membership event, the free Annual Meeting featuring dynamic national and regional speakers, Society awards recognizing our members, a peer and two RFM poster presentation opportunities, a free integrated care training, and our continued collaboration with members and community agencies in our work for behavioral health and our communications in the Newsletter.

In this edition of our Newsletter, we meet a fellow APS member based in Flagstaff, Arizona who also shares the distinction of the Nathan Avery Physician of the Year Award for 2016 recognizing him out of many physicians in other specialties within Northern Arizona's healthcare system. 
We highlight diversity with a contributed article from Benjamin Walker of Austin PrEP Access Project, on HIV Prevention Medication and Mental Health: How PrEP Impacts Gay and Bisexual Men; instructions on how to join a Minority or Underrepresented Caucus of the APA; and a story celebrating Dr. Jeffrey Akaka, Hawaiian Physician of the Year 2016, and his family's historical connection to the flower leis worn by the marchers on Selma in 1965. 
Dr. Noggle shares with us with the latest updates on mental healthcare throughout Arizona, as well as discussion on the advancement of the Stepping Up initiative--driven to help reduce individuals with mental illness in Arizona's jail system. 

Dr. Bastani, APS Ethics Committee Chair, shares with us his experience in a workshop led by distinguished psychiatrist Dr. Glen Gabbard in discussing social media and our practice. 

Finally, Dr. Reesal shares some eye-opening statistics of his current country of residence, Liberia, as well as his first-hand experiences. 

Our newest APA Distinguished Fellows and Fellows are listed in this edition, so please congratulate those you know fondly within your community. 

Warm Regards,


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 Fall Reception at The University Club Hosted by Valley Hospital - Phoenix:

Gurjot Marwah, MD
Arizona Psychiatric Society, President

As a highlight to the ending of 2016, in early December the Society reached out to Senators Flake and McCain to encourage their favorable vote on the modified 21st Century Cures Act (H.R. 34), which was later overwhelmingly passed by both the Senate and the House and signed swiftly into law by President Obama.  The fruition of more than three years of multi-pronged campaigns for mental health reform supported and advocated for by the APA and APS, the package included landmark provisions from several acts, most notably that commonly known as the Murphy Bill (The Helping Families in Mental Health Crisis Act).  Each of you has played a pivotal role in the advancement of mental health reform over these past years, through your membership, leadership, and grassroots advocacy, which were vital to this effort, and to our continued efforts for the extension and enforcement of parity and its related reforms, and we thank you.  

Reflecting on the earlier months in the last year, I thank all of the members who contributed through leadership and participation in our many successful events and efforts (as detailed by Dr. Amini above), and I hope that the new year is off to a great start for all.  Speaking of the new year, I hope you will plan to attend the 2017 Annual Meeting on May 6, 2017 at The Buttes Resort in Tempe.  The proposed Agenda for the meeting offers high caliber education for psychiatrists, psychologists, and many other behavioral health partners, and includes presentations on Dialectical Behavioral Therapy, Pediatric Movement Disorders, Treatment of Major Depressive Disorder, and Neurobiology and Psychiatry.  

In the new year, as your President, it is my goal for our leadership to continue to build the Society through the growth of its membership and to strengthen the connection of psychiatry to our behavioral health partners through collaborative efforts and educational outreach.  I hope you will join me by inviting a psychiatrist peer to join the Society or inviting a behavioral health colleague to attend the 2017 Annual Meeting.  Thank you for your membership, which makes all the Society does possible.  We stand stronger together!  

Chair, Department of Psychiatry, Flagstaff Medical Center/Northern Arizona Healthcare; 2016 Recipient: Nathan Avery Physician of the Year 2016
It was a few years ago and my daughter Brie was a bubbly and inquisitive two year-old.  She and her mommy (my wife, clearly expectant with our second child at the time) were visiting me one call evening as I worked the psychiatric emergency services.  Our little family was eating a simple dinner together in the cafeteria of the university's psychiatric hospital.  It was a busy evening, and the small cafeteria was full of the commotion of people coming and going.  Some were outpatients who had just wrapped up group therapy where they had learned a new DBT skill.  Others were grabbing a quick bite after outpatient appointments in the Dual Diagnosis Clinic.  Some appeared internally preoccupied, perhaps struggling with psychotic symptoms, or deep in thought having come from an individual psychotherapy session.  Others appeared to be the anxious family members and loved ones of patients being evaluated in the psychiatric emergency department. 

At our small cafeteria table that evening, my wife and I were discussing feelings with our little one.  "I'm happy," I exclaimed with a smile.  Glancing quizzically at my wife, I inquired, "Are you happy?"  "I'm happy," she chimed in.  Casting her brown eyes and warm smile on our two-year old, she asked, "Are you happy?"  Catching on to the game, her developing mind whirring almost audibly, little Brie smiled cheerily, and exclaimed, "I'm happy!" 

Then the unexpected...  Brie turned to a weathered, gruff-looking man with a scraggly beard the color of old newspaper and asked, "Man, are you happy?"

Now it was my mind that began to whirr...  Through perfect trust and good intentions, my daughter had attempted contact with another human being; one who appeared to be so very much in need of precisely that form of contact.  I imagined what the gentleman might be thinking, having just been asked about his mood by a smiling two-year old in pigtails.  I wondered what he might be feeling, seeing the little girl before him in the white and yellow dress glancing up with her large brown eyes.  Was he happy, I wondered? 
Psychiatry is a truly wonderful specialty.  The recent changes that have been happening in our field are remarkable.  In the short time since completion of my training, borderline personality disorder has gone from a chronically debilitating illness with few evidence-based treatment options, to a manageable disorder that has up to an 85% cure rate.  We are increasingly aware of the fact that ADHD is an illness that impacts patients across the lifespan, and we are doing a better job treating it.  The massive over-diagnosis of bipolar disorder in children and adolescents has been acknowledged, and efforts are being made to improve diagnostic precision. As a field, we have reconnected with the realization of the terrible and lasting detrimental effects that result from complex developmental trauma and adverse childhood experiences. Cognizant of this, the burgeoning field of infant mental health harnesses a strengths-based approach that is prevention-focused.  Motivational interviewing and new pharmacotherapies, such as the naltrexone extended-release injectable suspension, are offering hope to individuals struggling with the repercussions of the opioid epidemic.  New and interesting research is ongoing to better understand the role of glutamatergic signaling in schizophrenia, while schizophrenia itself is no longer conceptualized as a single illness, but as a group of similar illnesses (the schizophrenias).  Long acting injectable antipsychotic medications offer improved adherence to treatment in conditions (the schizophrenias) among which adherence is essential in order to create the conditions that give our patients the best possible prognosis.  While electroconvulsive therapy continues to be a gold-standard treatment for certain illnesses, our treatment options have expanded with the development of repetitive transcranial magnetic stimulation.  Various imaging modalities and genetic testing are the focus of interesting research, and some forward thinking psychiatrists have already begun to obtain genotypic testing for cytochrome P450 polymorphisms in order to help inform their selection of SSRI and other psychotropic medications.  These are just a few examples of the many wonderful changes and advances happening in psychiatry.

However, none of these advances are as important as the most fundamental therapeutic approach at our disposal: our ability to develop an empathetic connection with our patients. 

That is why I was so very proud of little Brie, my two year old, when she turned to the gruff-looking man sitting near her in the psychiatric hospital cafeteria and inquired about his mood.  Her effort represented the developmental spark of an empathetic connection with another human being... the most powerful clinical tool in psychiatry.
Dr. Adam Graff is the recipient of the Nathan Avery Physician of the Year for 2016, an award recognizing one of the 375 physicians from all specialties within in the Northern Arizona Healthcare system.

It was great to see primary care and psychiatric physicians and other providers at the Arizona Integrated Care Training on October 29, 2016.  Thanks to panel participants Drs. Fowls, Bartos, Paul, Cattelino, and Roberts for the shared perspectives on integrated/collaborative care, Dr. Raney for the insightful training, and Dr. Fowls (PII) and Ms. Kroeger (APA) for insights into the state and national collaboratives. Most importantly, thanks to the University of Arizona College of Medicine, Phoenix (coordinated through Dr. Fran Roberts) for providing the site and support services for such a great meeting. The staff and facilities are truly amazing.  

Integrated care training continues to be available from the APA through its free 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.
From the Arizona Integrated Care Training, Photographed below:  Clockwise from Left:  Dr. Fowls and Dr. Paul; Dr. Narine and Dr. Merrill, Dr. Brown, Dr. Dan Merrill, and Dr. Jerilynne Merrill; Dr. Raney and Ms. Kroeger; and Panel members Drs. Fowls, Bartos, Paul, Cattelino, and Roberts.  

During and at the conclusion of the Integrated Care Training, Arizona Resident-Fellow Members presented posters to meeting attendees and for judging for scholarship prizes.  Photographed below (Clockwise from Left:  Poster presenters Drs. Cochran, Shao, and Chong; Dr. McClure presenting to Drs. Stumpf, Singh, and Sadr; and Poster winners and their judges (Judges Drs. Sadr and Kafer, 2nd Place Dr. Chong, 1st Place Dr. Shao, 3rd Place Dr. McClure, and Judge Dr. Stumpf).  


Support local psychiatric residency research by completing this brief survey (link below). This survey is part of an ECG study at Banner University Medical Center Department of Psychiatry. The ultimate goal of the study is to develop standardized clinical guidelines for ECG monitoring in patient treated with psychiatric medications. In order to do so, a team of residents is conducting a retrospective cross-sectional review of ECG data from 520 patients admitted to BUMCP behavior health in 2015, performing extensive literature reviews and eliciting expert opinions from psychiatry, internal medicine, cardiology and toxicology. This survey is essential to understanding the standard of care for ECG monitoring in Arizona. The researchers greatly value your opinion and your time in completing this survey.

Looking for a psychiatrist licensed in Arizona who is interested in a part-time position as a psychiatric consultant to primary care clinics serving Medicare patients.  Job would be working within the collaborative care model providing curbside consultations and behavioral care manager registry reviews weekly.  Position does not have to be onsite - can occur remotely although a visit to meet the primary care providers and possibly provide some educational sessions is preferred.  Job would be 2 hours per care manager and could increase over time depending on volume.  If interested please contact Lori Raney, MD at or call 970-759-9461.   
How PrEP Impacts Gay and Bisexual Men
Benjamin Walker, MGPS
Executive Director, Austin PrEP Access Project 

For the first time, individuals at high-risk of becoming HIV-positive have a medication that they can use to protect themselves from infection. Designated an "important milestone in our fight against HIV" by Commissioner Margaret Hamburg, MD, Truvada for HIV Pre-exposure Prophylaxis received FDA approval in 2012.[1] Two years later, the CDC issued its first recommendation and treatment guideline for the HIV prevention strategy, now colloquially known as PrEP.[2] In 2015, the CDC furthered its support, estimating that 1 in 4 sexually active gay and bisexual men should be offered HIV-prevention medication.[3] As the use of PrEP expands and gains popularity, its impact on the mental health of patients become more apparent. This paper explores how the availability of PrEP has led to (1) a reduction in fear and anxiety and (2) increased self and community empowerment for gay and bisexual men.
Feelings of fear and anxiety are, unfortunately, accepted norms at sexual health clinics.  People sit nervously in waiting rooms anticipating to be diagnosed with HIV or other sexually transmitted infections (STI). A specter of shame permeates the space as patients await judgment from their medical provider and society at large.  Other than obtaining treatment for a painful infection or a temporary respite from the fear of HIV, there is very little incentivizing this uncomfortable intrusion into one's daily life. The patient is unlikely to return until he is again driven by fear, anxiety or painful urinary symptoms.
PrEP has the potential to transform this paradigm. Following the CDC's PrEP guidelines, a patient takes a daily pill, and receives quarterly STI screenings from his provider. Unlike the experience described above, the patient now self-selects to engage in regularly scheduled preventive visits. Eventually, these screenings become a normal part of the patient's life. This not only makes it a much less traumatic experience, but also provides a framework for a more open and honest conversation between the patient and provider. It is common to see PrEP patients, initially sheepish and quiet, become visibly more confident-even initiating conversations with clinic staff or other patients in the waiting room. Doctors who are patient-focused rather than values-focused gain trust and become known within the community. Patients with strong relationships with their doctors are more equipped to communicate accurate sexual health information within their peer groups and correct common misconceptions.
While what goes on inside the clinic is certainly important, it is what is happening outside of the clinic that is most noteworthy. Across the country, gay and bisexual men are experiencing something that this demographic has not known in over three decades-sex without fear. Gay and bisexual men who lived through the AIDS epidemic during the 80's and 90's experienced the trauma of watching their friends, partners, and loved ones die. Since then, sex between men has always been tinged with the fear of AIDS-related death. Many gay and bisexual men thought of HIV not as an "if" but as a "when". Carrying this pain and dread around with them at all times, HIV-negative men often avoided sex in fear of becoming positive and HIV-positive men often became abstinent in fear of transmitting the virus to a partner.
The impact of unloading decades of fear and trauma can be overwhelming. When PrEP was first introduced, its harshest critics came from within the gay and bisexual community. There was anger, hurt, distrust, envy, and judgment:
Where was this medicine when I needed it?
Why did I have to go through all this pain?
Are you taking this because you are promiscuous?
Even louder than the critics, however, were the voices of relief and exhilaration. PrEP users found that releasing their HIV trauma had myriad overlapping benefits to their physical and mental health. Damon Jacobs, a licensed marriage and family therapist who frequently speaks on the topic of PrEP, explains,
"Feeling protected from HIV helps me to feel more affirmative sexually. Feeling affirmative sexually gives me more confidence and energy. More confidence and energy leads me to exercise consistently and eat healthier. Exercising more and eating healthier gives me more strength and confidence. Having strength and confidence promotes improved mood, happier relationships, and more satisfaction in my professional life, which all positively impacts my physical health."[4] 
Like Jacobs, many PrEP users report that they have become more focused on their health. This effect was documented in iPrEx, the first randomized clinical trial of PrEP.
The protection afforded by PrEP is also challenging a community segregated by serostatus. The once pervasive practice of "sero-sorting" (HIV-positive men seeking only HIV-positive partners and HIV-negative men seeking only HIV-negative partners) is now being dismantled. With the ability to protect one's self from HIV, conversations about HIV status are more common and less fearful. Dating and relationships between HIV-positive and HIV-negative men are more visible and less exceptional.
The implementation of PrEP has proven to be an opportunity for vigorous discussion, healing, and unity. As we move into 2017, PrEP is overwhelmingly endorsed, both nationally and internationally, by governmental health agencies, HIV/AIDS organizations, and community health groups. While PrEP uptake among gay and bisexual men continues to increase, engagement in PrEP has been significantly slower within communities of color. Additionally, access to HIV-prevention medication is largely unavailable outside the USA. As we observe individuals and communities becoming less anxiety-driven and more unified and empowered in response to HIV, it is essential that we continue to advocate for those who do not yet have access. As we continue to fight for an HIV cure, we no longer have to live in fear of the virus.     

[1]FDA. (2012, July 16) FDA Approves First Drug For Reducing the Risk of Sexually Acquired HIV Infection. Retrieved from 
[2] CDC. (2014, May 14) New Guidelines Recommend Daily HIV Prevention Pill For Those At Substantial Risk. Retrieved from 
[3] CDC. (2015, November 24) New CDC Estimates Underscore The Need To Increase Awareness Of A Daily Pill That Can Prevent HIV Infection. Retrieved from 
[4] Jacobs, Damon. (2013, November 26) Unintended Side Effects Of PrEP. Retrieved from 

About the Author:  Benjamin Walker ran the Health Insurance and Medication Access program at AIDS Services of Austin for three years before founding the Austin PrEP Access Project (APAP) in December 2014. APAP began as a patient navigation program, linking Austinites at-risk of HIV to medical providers willing to prescribe HIV prevention medication (AKA pre-exposure prophylaxis or PrEP). In May 2015, with the help of Dr. Cynthia Brinson, APAP opened the Austin PrEP Clinic, the first PrEP clinic in Central Texas and the only volunteer-run PrEP clinic in the nation.  Since then, the Austin PrEP Clinic has served over 500 patients. Ben is proud to serve as the Executive Director of Texas Health Action, APAP's parent nonprofit, and is passionate about eliminating healthcare disparities across the state. Ben received his Bachelor's degree from Austin College and his Master's from the LBJ School of Public Affairs at the University of Texas at Austin.

If you would like to join the a Minority and Underrepresented (MUR) Group Caucus, to keep abreast of cultural issues and resources at the APA, please go to the APA website ( Click on PSYCHIATRISTS, then Cultural Competency, then Minority and Underrepresented (MUR) Group Caucuses, and then Join a Minority and Underrepresented Group Caucus. You will be asked to sign in with your APA username and password. Once you sign in, select the MUR Group to which you wish to belong.

The MUR caucuses provide a networking opportunity and foster communication among members who share interests. There are caucuses for the following groups:
  • American Indian/Alaska Native/Native Hawaiian
  • Asian-American
  • Black
  • Hispanic
  • International Medical Graduates
  • Women
You may join more than one caucus, but you need to indicate in which caucus you wish your voting rights to reside.  You must be a member of the caucus to elect voting rights in the same.  
Jeffrey Akaka, MD
Shares Family Connection to Hawaiian Leis Worn by Marchers at Selma

We share with you the acceptance and thank you letter of APA Representative Dr. Jeffrey Akaka, who, upon acceptance of the Hawaii 2016 Physician of the Year Award, shares his personal story of the importance of service, the meaning of "Aloha," and his family's connection to the flower leis worn by Dr. Martin Luther King, Jr. and fellow marchers at Selma on March 21, 1965.  (Photo below).  CLICK HERE for the full acceptance letter.  We celebrate Dr. Akaka and the truth and power of his message and congratulate him on a distinction well deserved.    

Lifewell is recruiting for Psychiatrists and Psychiatric Nurse Practitioners in the Phoenix area! At Lifewell, you'll join a team passionate about providing hope, healing and health to the ones we serve. Our mission drives us, and you'll see this in our desire to help others reach a balanced mental health lifestyle.

Enjoy competitive salaries, incentive opportunities, full benefits, flexible work schedules and NHSC accreditation!

Contact Human Resources at 602-599-5591 for more information or submit your employment application at Come alongside us and watch lives change!


Fellow definition
Please join the Arizona Psychiatric Society in congratulating

Marcelle B. Leet, MD, DLFAPA

as a newly designated Distinguished Life Fellow, and

Roland Segal, MD, DFAPA

as a newly designated Distinguished Fellow of the American Psychiatric Association.

In addition, please join the Arizona Psychiatric Society in congratulating each of the following newly designated Fellows (or Life Fellows) of the American Psychiatric Association:  

Mona Amini, MD, FAPA
Sandra Ann Jacobson, MD, FAPA
Saul Gilberto Perea, MD, FAPA
Sami Victor, MD, FAPA
John Thomas Zaharopoulos III, DO, FAPA
Pamela T Frazier, MD, LFAPA
Lawrence M Martin, MD, LFAPA

Each of these newly elected Fellows or Life Fellows will be recognized at the 2017 Convocation of Fellows, during the APA Annual Meeting in San Diego, CA.  We congratulate these members on the well-deserved recognition.  

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

The Arizona Psychiatric Society thanks Dr. Noggle for the update to her earlier article, shining light on the work by Maricopa County, counties across Arizona, and community organizations, including David's Hope, NAMI Arizona, Mental Health America Arizona, and many others, to advance Stepping Up initiatives to reduce people with mental illness in our jails.  Dr. Noggle provides a comprehensive update and several additional linked resources for the benefit of our readers.  We look forward to continued updates on progress made in Arizona and hope you will be a part of this important initiative.  

Across the country, counties are responding to the Stepping Up action call to reduce people with mental illness in our jails: 300 Counties, representing 41 states as of September 2016. Arizona is leading the country with all but 2 counties signing Stepping Up Proclamations. As Jim Dunn, Executive Director, NAMI (National Alliance on Mental Illness), says, "Arizona is indeed fortunate to have powerful leaders like Mary Lou Brncik, Founder/Director of David's Hope and Ring Leader of the AZ Mental Health and Criminal Justice Coalition. Mary Lou's determination to lead Arizona' s Stepping Up Initiative inspired Arizona's Public Health Leadership to contract with her through NAMI Arizona's Building Connections Partnership to grow the intentional partnering among highly diverse, traditionally adversarial groups now focused on nonpartisan results to keep individuals with mental illness in treatment and not behind bars." (Information is posted below regarding NAMI's annual meeting). 

David's Hope, composed of family members and people with lived experience, is responsible for activating many counties, a true sign that this is a grass roots movement as well as a commitment of regional governments. Governor Doug Ducey has registered his support for reducing recidivism overall as well: "We're committed to continue everything we can to reduce recidivism". In October 2016, Arizona Department of Corrections was awarded a Second Chance grant targeting services to reduce recidivism for higher risk offenders. 

Local communities continue to develop strategies to keep people from entering jail at the first "intercept" or nexus with the justice system (see link for SAMHSA GAINS Center Sequential Intercept Model). Arresting agencies are increasingly implementing CIT (Crisis Intervention Training) across the state, resulting in untold numbers of people in acute mental health crises not getting booked into jail. In Maricopa County, over 1,000 individuals monthly are taken to crisis centers. Crisis mobile teams, available throughout the Valley, are called approximately 300 times a month to facilitate on the spot crisis intervention. The Valley has an effective, geographically ranging psychiatric urgent care system: UPC (operated by Connections AZ), East Valley Community Psychiatric Emergency Center (operated by Community Bridges as well as their Transition Point services in Avondale) and West Valley Recovery Response Center (operate by Recovery Innovations). This system works closely with arresting agencies to make diversion of individuals from jail a safe and quick process. It takes less time to take someone to a secured psychiatric urgent care center than to book him or her in jail. Yavapai County was recently awarded a $250,000 Bureau of Justice Mental Health Collaboration and Planning Grant, spearheaded by Chief Deputy David Rhodes to examine the various opportunities to divert, identify and provide treatment and community transition to their population, another effort to celebrate.

We know that these efforts are paramount to Stepping Up. In examining our data for individuals booked into Maricopa County jails for 2015, we know that 1 in 4 report homelessness upon entering jail. Incarceration renders housing status precarious as once incarcerated, people cannot pay rent, keep jobs, and lose housing. Recently, Dr. Ryan Cotter, Maricopa County Justice Systems Planning and Information, corroborated national research regarding impact of incarceration on low risk offenders. Individuals detained for as few as 72 hours are at significant risk for recidivism within 12 months of jail release. Most seriously mentally ill individuals are arrested for nonviolent, misdemeanor offenses. Many individuals cannot afford the $200 to $500 needed to be released from jail, leaving many within jail well beyond 72 hours. In fact, the most frequent reason for arrest is Failure to Appear to court (for individuals designated SMI). Let's consider this together: Seriously mentally ill people often get arrested for a simple failure to appear at court or another minor offense; they are often unable to pay fines and fees resulting in remaining jailed which leads to greater risk for re-arrest, loss of housing and further negative impact on their social support and care system. (Stay tuned for the various reforms being developed by the Fair Justice Task Force, called by AZ Chief Justice Scott Bales, to reduce inequities based on ability to pay, including reducing fines and fees for indigent individuals).

Once individuals with serious mental illness are incarcerated, there are effective strategies to reduce further contact and/or "failure" in the justice system. There are successful Mental Health Courts across the Valley, from Glendale (see link below regarding Judge Elizabeth Finn's great work) to Tempe. Phoenix started its Behavioral Health Court, expanding defendants beyond individuals with SMI designation, and has served 1,150 individuals since its inception January 11, 2016 according to Judge Michael Hintze. 

We also know that Stepping Up means better coordination of care and communication regarding health status for all individuals, and particularly those whom are vulnerable due to chronic health, behavioral health and substance use conditions and disorders. AHCCCS (Arizona Health Care Cost Containment System) has led a Justice Transitions Initiative since 2015 ranging across most counties to facilitate and support these efforts. Medicaid is now suspended upon incarceration, not terminated. Jails, probation departments and health care organizations work to ensure individuals can re-engage AHCCCS eligibility and health care. Health Plans as of October 1 are required to "reach in" to jails and prisons for coordination of care for all individual with significant medical, behavioral health and/or substance use disorders and whom remain incarcerated for 30 days or more. This is a significant undertaking requiring Health Plans and the Justice system agencies (jails, prisons and their health care providers, probation and community supervision) to develop better processes for sharing health information to coordinate effective, supported transition to the community. Again, Stepping Up requires re-engagement in a system of health care and social support that must be responsive to the needs of justice involved individuals. At a very simple level, this means that a case manager understands that a court date is just as important as a clinic appointment and supports those early, crucial needs of the individual leaving jail. A great example of the power of improving collaboration and coordination of care is the Maricopa Adult Probation and MMIC effort to place probationers into residential substance abuse treatment directly from jail between. This enhanced collaboration has resulted in an 81% placement rate (up from last year's 12% placement). 

Finally and returning to where we started, Stepping Up requires peer and family involvement. No one can better understand the bewildering experience of navigating the criminal justice system than family members and those individuals with lived experience. Maricopa Mercy Integrated Care funds a vibrant array of peer run agencies and behavioral health agencies that are increasingly hiring forensic peers. We have to continue to find ways for these peers to have access to establishing contact and relationships with individuals before release from jail and prison to solidify successful community transition, the key ingredient to reducing recidivism. A new and exciting step toward this is MMIC's creation of a crisis response system Community Advisory Council composed of family members and peers. 

Saving the disheartening for last, I am including a link to the recently released "The State of Mental Health in America 2017". Once again, Arizona is leading last, ranking 50th out of 51 in the overall mental health rating (composed of 15 measures), 50th for youth, and 45th in adult incarceration (meaning we incarcerate more people per 100,000 than 44 other states). On the more positive side, we have increased access to care, thanks to Medicaid expansion, and are now 40th in the nation. Despite so much positive progress reported above, we know we have a long road ahead of us; we as a community of health providers are better than this. 

We must be grateful to MHA for the incredible contribution they continue to make in creating this report card. Stepping Up exhorts us to develop baseline data and to measure the impact of our various programs and strategies. Until we have the data, we have no guaranteed path to success in our collective mission. Let's not just hope, let's promise that these Stepping Up efforts in full swing across the state will transform our standing in the next MHA report, and most importantly, in the lives of the individuals and families that we serve and treat.

Resources and References
Article on Glendale mental health courts cutting down on recidivism

Mental Health America Arizona: November 22, 2016 Meeting of Association of Associations
(From MHA Arizona):  The A of A is a network of advocates who come together to discuss mental health issues in our community and the advocacy needs surrounding them. Together, we work to see change. This last meeting addressed the potential implications of the recent election and was attended by 48 fellow advocates. The meeting was recorded and viewed by 50 additional advocates whom were not able to attend our event in person. Speakers included: Emily Jenkins, Executive Director of Arizona Council of Human Service Providers, who spoke on state advocacy issues; Debbie Plotnick, Vice President Mental Health and Systems Advocacy at Mental Health America, who spoke on national advocacy issues and Shannon Groppenbacher, Policy Advocacy Director at Johnson & Johnson Health Care Systems Inc. who spoke on the need and strength on working together to make the greatest impact. To view the recording of the meeting, click here to visit the link to that recording.
NAMI Az logo updated banner

"NAMI AZ is very pleased to announce Dr. Dawn Noggle with Maricopa Correctional Health Services and one of the originator of the AZ Mental Health and Criminal Justice Coalition along with AHCCC leadership will lead a presentation, discussion and audience participation with RBHA, Health Plan, Governmental, and Community Leaders to wrap up our 1/28/17 NAMI AZ Annual Meeting Collaborative Community Oversight-AZ Steps UP. " (Jim Dunn, NAMI)

NAMI Arizona 2017 Annual Meeting
"Collaborative Community Oversight - Arizona Steps Up"
Saturday January 28th, 2017
Ability 360 Center
5025 E. Washington St. Phoenix, AZ 85034
9:30 AM to 3:00 PM

"Collaborative Community Oversight - Arizona Steps Up" recognizes that today's economic and political reality provide another perfect opportunity to strengthen our intentional partnering.  Arizona is blessed with numerous powerful and dynamic collaborative, coalition, alliance, and like-minded groups determined to promote, support, and grow positively transformative behavioral health, criminal justice, and correctional system outcomes.

So how do we connect them? How do we ensure the right voices are at the right tables and all feel heard? Can we implement systems, practices, and relationships that keep our fingers on the pulse while achieving desired individual and community results?  NAMI Arizona invites your input and participation.  

Jehangir B. Bastani, MD, DLFAPA
Ethics Committee Chair
Arizona Psychiatric Society

Following is the Report by Dr. Bastani from the November 2016 Ethics Workshop (a bi-annual event hosted by the APA for the continuing education of all of the Ethics Chairs and District Branch Executives).  CLICK HERE for the recommended article by Dr. Glen Gabbard, "Clinical Challenges in the Internet Era."

The meeting was an APA sponsored workshop held in Washington DC at the Omni Shoreham for Chairs of the Ethics Committee of State District Branches to educate and advise them of the changes facing practice of psychiatry. It centered on Contemporary Challenges in the Psychiatric Practice caused by Social Media. The workshop helped provide guidelines relevant to this in the daily interaction of psychiatrists with their patients. We are familiar with the "APA Principles of Medical Ethics with Annotation especially Applicable to Psychiatry". It is a necessary document that has grown. It is a well crafted work that is in constant evolution. It will have further changes in the future due to the Electronic Health Record (EHR) and other technological advances impacting our clinical practice.

Glen O. Gabbard MD led the Workshop with findings from a survey of practicing psychiatrists of social media and their practice. The findings of interest he presented of the survey were:

Do you use email to contact your patients? Never 50%; rarely 25%.
Do you exchange text messages with your patients? Never 74%; 25% maintain contact. Note of Caution: Text messages are reductive, can be easy for others to read, wrong texting (e.g. patient drunk while texting) and an expectation of immediate response.
Do you receive request for "Friend" from your patient? Yes 40%; No 60%
Are you "Friend" with your patients? No 94%; Yes 6%

Other question in the survey was googling about your patients was quite common in emergency room and forensic psychiatry but psychiatrist in practice would not consider it. Of course, patient may rate and they do google their psychiatrist commonly. Another issue was handling a patient/relative who presents a charming and appreciative front during therapy and thrashes the psychiatrist on the web page. It has implication for honesty, trust and boundaries issues during therapy.

He spoke of the psychiatrist's need for privacy as a thing of the past thanks to Google and other search functions and the disappearance of therapist anonymity. Example was cited of listing on a dating website as there is a blurring of public and private persona. Dr. Gabbard stressed to the participants that Internet is a permanent record, encrypted or not. Subsequent speakers reinforced this. An analogy made was the false belief of internet privacy as a vacation picture-postcard mailed expecting the 'village' not to know about your trip destination. The difference is that the picture postcard fades with time! It is best to avoid all social media platforms when it comes to personal information for now. 

He directed us to his article "Clinical Challenges in the Internet Era" (Gabbard, G.O.: Am J Psychiatry May 2012 pp.460-464) which is a Clinical Case Conference. The discussion is enlightening and shows us the unusual constraints we face in working with our patients. TAKEAWAY: I recommend this article be read by the membership.

Colleen Coyle JD; APA's General Counsel spoke on the process of what happens when a complaint against an APA District Branch member is lodged at the District Branch Level. This does not apply to non-DB members as they are outside our jurisdiction. She reminded us of the gravity of the complaint lodged and its impact on our member's reputation. She described the nature of External Evidence presented by the Complainant. Anonymous complaints are not considered evidentiary and so cannot be acted upon. An interesting twist is that if a complainant lodges a complaint before the State Board Of Medical Examiners (BOMEX) as well as the District Branch (DB), this results in the DB not pursuing it as it avoids duplication. BOMEX is a legal state entity and its deliberation takes precedence over the Ethics Committee deliberations. BOMEX deliberations are formal from the time they receive a complaint. 

The DB on receiving the complaint initiates a preliminary deliberation by the Ethics Committee. This preliminary investigation remains informal with the exploration of the evidence lodged, evaluating if it is true, whether a violation has been committed and obtaining information from the DB member. It is only after exploration and weighing the evidence obtained from all parties that a decision is made for dismissal of the complaint or non-dismissal. At the District Branch level, the whole process is an informal one. In the event of non-dismissal of the complaint lodged, it is then along with the deliberation's finding of the DB Ethics Committee, forwarded to the APA Central Office. They in turn review the forwarded findings and deliberate to dismiss or will inform the APA member that a formal investigation will proceed.
The next morning of the Workshop was devoted to role-playing and coming up with solutions to various hypothetical situations of complaints (based on similar past cases brought before the DB Ethics Committee). We were separated into five small groups that each had a moderator who belonged to the APA's Ethics Committee and who brought their experience. Of interest was their sharing how they would resolve these cases and what potential twists and turns we could encounter. APA Counsel Colleen Boyle reminded us that the Ethics Committee exploration and deliberation process is in the nature of Peer Review and therefore complies with the Health Care Quality Improvement Act (confidentiality etc.).

Payam Sadr, MD, FAPA, Arizona APA Assembly Representative
Aaron Wilson, MD, FAPA, Arizona APA Assembly Representative

The November Assembly in Washington, DC included reports and updates from all divisions of the APA and a diverse array of advocacy and action paper discussions.  We encourage you to read the Assembly Notes for all the news from the November Assembly! 

Some highlights of the reports include the current initiatives on health care reform, include: health plan network adequacy, funding to audit health plans, public reporting on parity investigations, and producing a consumer guide to disclosure rights. APA is making MACRA implementation for Medicare providers as user-friendly as possible, to include reporting exemptions for practices treating less than 100 Medicare beneficiaries, decreasing and making reporting requirements more flexible, and developing a registry - called PsychPRO - to facilitate MACRA reporting for members. APA is using their TCPI-SAN Grant to facilitate over 500 psychiatrists to date in Integrated Health Care, and plans to train several hundred more. APA will be taking occupancy of its recently purchased new office space in 2018, after completion of construction and renovation.  

Among the more notable Actions taken during this session, the Assembly voted to:
  • Approve (on consent) proposed APA Position Statements on Out-of-Network Restriction of Psychiatrists, Location of Civil Commitment Hearings, Mental Health and Climate Change - all based on previous Assembly Action Papers;
  • Approve the improved communication between outpatient and inpatient (hospitalist) physicians;
  • Explore (with AMA) models for single payer and universal healthcare access delivery;
  • Ensure privacy of protected health information in access of PDMP databases by law enforcement;
  • Urge APA develop Position Statements on Screening and Treatment of MH Disorders during Pregnancy and Post-Partum and increase Parity of MH Care for persons with Intellectual and Developmental Disabilities;
  • Urge APA to improve liaison between APA fellowship applicants and recipients and their local DBs;
  • Urge APA to support smart-gun technology as part of an effort to reduce gun violence as a public health concern;
  • Urge APA to advocate for improved quality and access to medical and psychiatric care in correctional and institutional settings;
  • Urge the APA to collaborate with other state and national groups to combat the consequences of childhood poverty and to end this public health problem;
  • Have the BOT form a Task Force on combatting Discrimination and its MH consequences;
  • Reaffirm the requirement of medical training for anyone who prescribes psychotropic medications;
  • Develop a fund with APAF help to pay costs of consumer speakers who present at APA meetings;
  • Reaffirm several current APA Position Statements, which can be found in the Assembly Packet;
  • Approve the proposed Position Statement opposing Psychiatrist prescribing or administering any euthanizing intervention to a non-terminally ill person.
  • Refer a Position Statement on Confidentiality of Medical Records of Physicians who have previously been in treatment back to JRC for revision to address practices of state Medical Boards publically posting such information on their websites.
Links to more information available on the full Action Papers is available in the Assembly Notes.  

MIHS recently opened its new adolescent unit, First Episode Center, located at the Desert Vista campus, 570 West Brown Road, Mesa.  MIHS chose the treatment model of care, Collaborative and Proactive Solutions, an innovative approach to inpatient adolescent psychiatric care developed by Dr. Ross Greene.  This model was developed on the premise that kids are lacking the skills to handle certain demands and expectations, and thereforerespond with challenging behavior, as the demands have exceeded the child's capacity to respond adaptively.  

The Medical Director of the Unit is Child and Adolescent Psychiatrist Dr. Claire Sollars.  For a printable brochure regarding the First Episode Center, CLICK HERE.  For a First Episode Referral Form, CLICK HERE.  If you wish to refer a patient to the MIHS adolescent unit, please contact the Admissions Department at 480-344-2195.   


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  

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.  

Medicare Payment Reform Toolkit:  Helping You Navigate Medicare Payment Reform
CLICK ABOVE for the Toolkit
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. APA is here to help you decide what is best for your practice. To learn about these new programs and requirements, we recommend first starting with the MACRA 101 Primer in the Payment Reform Toolkit. Then you can move on to fact sheets for more detailed information regarding the Merit-Based Incentive Payment System (MIPS) performance categories and "Advanced" APMs. We also recommend watching the webinar series, which includes a basic "Quality Reporting 101" webinar for psychiatrists with limited experience in quality reporting.

Each month APA makes available a free CME course exclusive to members only through its Learning Center. January's course is "Evaluating and Managing Agitated Patients."  This presentation reviews evolving approaches to managing agitated patients and offers suggestions to help not only psychiatric residents and trainees, but also seasoned emergency department and psychiatric emergency services staff to manage difficult patient populations. CLICK HERE for more information.

2017 GRAND ROUNDS FOR THE DEPARTMENT OF PSYCHIATRY BANNER-UNIVERSITY MEDICAL CENTER PHOENIX MOVED TO MEDICAL EDUCATION CLASSROOM-C (across from the Amphitheatre).  Held on scheduled Fridays from Noon to 1 pm, the January Grand Rounds schedule includes suicide prevention, clinical UDS interpretation, and gambling disorder presentations.  For the full Schedule, CLICK HERE.  

Southwest Psychoanalytic Society New Biennial Series:  The Enduring Legacy of Psychoanalysis:  Research and Clinical Practice Presented by Professor Alexander Lemma, "Minding the Body: Body Modification, Technology and Sexuality: Transsexual Identity," Saturday, January 14, 2017, 9:00 am to 3:00 pm at Hacienda Del Sol Guest Ranch Resort, Tucson, Arizona.  CLICK HERE for the flyer; visit for additional information or other upcoming seminars.


CLICK HERE for a printable pdf explaining treatment choices for schizophenia, schizoaffective disorder, and bipolar disorder, including information on long-acting injectables.  


APA/APAF Fellowships allow residents and fellows to expand their skills and explore interests while completing their regular training program. Many come with funding for projects or research and provide an excellent opportunity to connect with colleagues from across the country. Applications are due January 30, 2017.  Explore the fellowships today.  

Psychiatry with a Global Perspective
December 2016
Robin T. Reesal MD, Psychiatrist in Liberia

Dr. Reesal, an Arizona Psychiatric Society member, has been working internationally since 2014, and he provides this personal perspective on the living conditions in Liberia, where he and his wife have lived and worked for the last six months.

This article highlights Liberia, Africa, where my wife and I have lived and worked for over six months. It is one the world's poorest countries and recently known for the Ebola outbreak. 
Liberia, a country of four million people has an equal number of men and women. A third of the population is less than ten years old and four people a household is the norm. 
The World Bank whose mission is "Our dream is a world free of poverty" has changed its definitions of poverty to match changes in the value of money. Extreme poverty is now defined as living on less than 1.90 USD per day. 

According to the World Bank, half of the extreme poor live in Sub-Sahara Africa. Globally, about 767 million live in poverty, usually in rural areas and they have minimal education. 

These numbers have greater meaning when examined from the World Bank's four-dimensional model of poverty, which shows their vulnerability. Those living in poverty lack economic opportunities. Their capacities are limited due to poor health and education. They lack security from violence, economic shocks and environmental disasters. Last, they have minimal power to influence decision makers who control their environment and their lives. 
In Liberia, close to fifty-five percent of the population is defined as poor. The rate is seventy percent in rural areas. About twenty-five percent of the rural population live in extreme poverty with fifty percent saying they do not have enough money to eat. Living on less than two dollars per day is a stark contrast to the median wage in the U.S. of one hundred and forty five dollars per day. 

According to Liberian statistics, about two thirds of Liberians can read and write. There is a gender literacy gap with eighty percent of men described as literate compared to fifty five percent of women. Most are educated at government schools. About forty-three percent complete primary school. Twenty-one percent complete junior high and twenty-eight percent finish high school. About eight percent reach university.
These statistics when compared to the United States underline the disempowering effect of poverty. According to a 2016 U.S. census report, nine out of ten adults in the U.S. have a high school education or GED with nearly a third obtaining a bachelor's degree or higher. 

According to the Liberian Ministry of Health, there were 117 doctors in Liberia in 2015. The reasons for the doctor shortage include the civil war from 1989 and 2003, about three quarters of local graduate doctors emigrated to other countries and deaths due to Ebola. 
About sixty percent of Liberians access government outpatient and inpatient medical facilities when needed. Close to thirty percent access private non-religious providers. Rural communities rely more on government clinics than urban areas. For eighty percent of Liberians, medical treatment will cost less than 2,000 Liberian dollars or 20 USD. Universal health care is not in place at this point. 
Child and Maternal care is an issue in Liberia. Liberia's maternal death rate is one of the highest in the world at 750 per 100,000 (some say it is closer to 1,000/100,000). Sadly, two leading causes of death at childbirth are bleeding and infection, both usually preventable. 
Perhaps one of the most striking health statistics is that 99% of global maternal deaths occur in developing countries. This means about 830 women die every day globally from preventable causes related to pregnancy and childbirth. The maternal mortality ratio is 239 per 100,000 in developing countries vs 12 per 100,000 in developed countries. 

I cannot say much about mental health statistics because the data is limited. The country has one major psychiatric hospital. This Fall Liberia doubled the number of practicing psychiatrist from one to two. Stigma, traditional healing beliefs, lack of infrastructure, lack of medications, and lack of human resources are typical problems for mental health here and other African countries. 
War & Peace
Liberia went through about 14 years of civil war that ended with the Accra Comprehensive Peace Accords in August 2003. The United Nations Mission in Liberia (UNMIL) provided logistical and military support to stabilize the transitional government. Legislative and Presidential elections took place in 2005. Ellen Johnson- Sirleaf became the first Liberian female President and the first democratically elected African female president. She continues to hold this position. UNMIL left in the summer of 2016, post-Ebola. 
Outstanding Liberians Win Peace Prize in 2011
Ellen Johnson- Sirleaf was awarded the Nobel Peace Prize for her work towards peace and women's rights. She shared this peace prize with two other women, Leymah Gbowee another Liberian and Tawwakol Karman from Yemen, for their "non violent struggle for the safety of women and for women's rights for full participation in peace building work". The biography of President Ellen Johnson Sirleaf and Ms. Leymah Gbowee's offer an opportunity to understand the recent history of Liberia. 

President Johnson Sirleaf known as Africa's Iron Lady, has a Master's Degree in Public Administration from Harvard University's Kennedy School of Government. In helping Liberia gain its stability, she spent a year in jail and survived threats from the former President Charles Taylor. She played a role in Taylor's downfall and forming the transitional government in 2005. She was the first woman to lead the United Nations Development Project for Africa. In 2007, President Sirleaf was awarded the U.S. Presidential Medal of Freedom, America's highest civil award. In 2010, Newsweek named her one of the world's top ten leaders.
Ms. Leymah played a pivotal role in uniting Christian and Muslim women in Liberia to end the Civil war in 2003. Ms. Leymah helped found the Women of Liberia Mass Action for Peace group that staged public protests helping overthrow then President Charles Taylor. According to the U.K. newspaper the Guardian in October 10, 2013 "The Hague court found Taylor guilty of 11 counts of war crimes, crimes against humanity, and other serious violations of international humanitarian law, including murder, forced labor and slavery, recruiting child soldiers and rape." Given Taylor's history, her steps were extraordinary. According to her biography, at one crucial point before the fall of Taylor, Ms. Leymah faced incarceration during a protest march. She threatened to disrobe, which according to Liberian traditional culture would bring a curse of misfortune upon the men around her. Her threat worked. Besides being a often sought speaker, Ms. Leymah has helped found and run several women's organizations. She holds a M.A. in Conflict Transformation Eastern Mennonite University in Harrisburg Virginia. She was Liberia's flag bearer for the opening ceremonies in London's 2012 Olympics. 
A life of contrasts
The four social aspects of poverty are painfully obvious daily. Living with the world's poorest is difficult and memorable. Nightly I see a Liberian woman who sleeps on the ground outside our apartment and refuses food. On my walks, I see rickety cars next to new Lexus's and Mercedes. I can walk beside a well groomed Liberian in a suit and one who is disheveled in worn out clothes. Being asked for money unofficially and officially is a part of life that Liberians want changed. The iron bars on our windows and the barbed wire on our compound's fence are standard. My observations are not a judgment of anyone but a statement of reality. 

Special People
Many kind and hardworking Liberians welcome visitors and share smiles despite their life. They are special. In my view, most Liberians care very much about their fellow citizens and their country. The two Liberians, who run the Non-Governmental Organization (NGO) Face Africa, where I have my office, are examples of the pride of Liberia. These people and many like them are special.
There are thousands of nameless volunteers and international helpers bettering the lives of Liberians. They deserve our thanks. The families of the healthcare workers who died during the Ebola crisis have sacrificed to keep us safe. At least one hundred and eighty four Liberian health professionals lost their lives to Ebola. They and their families deserve a special thank you. 

As we begin this new year, take a moment to thank people who make your life better. Saying thank you creates happiness and helps well being. Happy 2017 to all. 

CLICK HERE for a listing of references.