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Syllabus & Proceedings Summary

Integrating Science and Care in a New Era of Population Health

American Psychiatric Association 66th Institute on Psychiatric Services San Francisco, CA | Marriott Marquis October 30 – November 2, 2014 APA’s Leading Educational Conference on Public, Community and Clinical Psychiatry

CONTENTS Courses and Seminars ………..

1

Innovative Programs …………..

4

Forums …………..……………...

10

Lectures …………..…………….

13

Symposia …………..…………...

21

Workshops …………..………….

35

Posters Session 1 …………………

52

Session 2 …………………

71

Session 3 …………………

91

Session 4 …………………

110

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2014 INSTITUTE ON PSYCHIATRIC SERVICES

Courses and Seminars SEMINARS

COURSE OCT 30, 2014

OCT 30, 2014

THE INTEGRATION OF PRIMARY CARE AND BEHAVIORAL HEALTH: PRACTICAL SKILLS FOR THE CONSULTING PSYCHIATRIST: NEW ADVANCED COURSE

CPT CODING Director: Allan A. Anderson, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand CPT coding procedures and terminology; and 2) understand the new AMA/CMS guidelines. SUMMARY: This seminar is for both clinicians (psychiatrists, psychologists, social workers) and office personnel who either provide mental health services or bill patients for such services using "Current Procedural Terminology (CPT) codes, copyrighted by the American Medical Association. Seminar attendees are encouraged to obtain the most recent published CPT Manual and read the following sections: 1) the Guideline Section for Evaluation and Management codes, 2) the Evaluation and Management codes themselves, and 3) the section on "Psychiatry." The objectives of the seminar are twofold: first, to familiarize the attendees with all the CPT codes used by mental health clinicians and review issues and problems associated with payer imposed barriers to payment for services denoted by the codes; second, the attendees will review the most up-to-date AMA/CMS guidelines for documenting the services/procedures provided to their patients.

Director: Lori E. Raney, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: Make the case for integrated behavioral health services in primary care, including the evidence for collaborative care; describe the roles for a primary care consulting psychiatrist in an integrated care team; and, describe rationale for providing primary care services in the mental health setting. SUMMARY: This course is designed to introduce the role of a psychiatrist functioning as part of an integrated care team. The first part of the course describes the delivery of mental health care in primary care settings and includes the evidence base and guiding principles. The second part is devoted to reviewing approaches to providing primary care in mental health settings and the emerging models in this area. The material includes a discussion of both the evidence base for this work and the practical “nuts and bolts” for care delivery. Examples in diverse locations, emphasis on team building and settings will also be discussed. Four speakers including Jurgen Unutzer, M.D. and Anna Ratzliff, M.D., Ph.D. from the University of Washington, Department of Psychiatry, Lori Raney, M.D., Chair APA Workgroup on Integrated Care and John Kern, M.D., Chief Medical Officer, Regional Mental Health will present didactic material and allow ample time for questions and discussion.

OCT 31, 2014

APA & ACA, YES WE CAN! Report of the APA Presidential Task force on Equipping Psychiatrists for the Post-ACA Environment Director: Anita Everett, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the implications of the ACA for medicine and psychiatry, in particular; and 2) identify relevant APA resources applicable to one’s practice. SUMMARY: Update: Since the passage of the ACA four years ago, numerous opportunities have been created that impact psychiatric practice. The APA has addressed multiple components of ACA implementation within existing structures as well as through expert task forces that address aspects of ACA implementation. Now we are at a critical point… Moving forward over the next several years, what themes of the ACA will remain? what is vulnerable to change? and what do psychiatrists need to provide the best care to persons with mental illnesses in the US? Dr. Everett is the current APA Trustee-at-Large and has participated in multiple APA initiatives that involve implementation of the ACA. She has led the implementation of several integrated care projects within the Hopkins Healthcare System in Baltimore. In this session, psychiatric aspects of the ACA will be reviewed. ACA related APA products and resources will be discussed. Most importantly, we hope to have a robust discussion regarding how ACA has impacted the practice of psychiatry in the US, and what the APA and organized medicine can do to facilitate better practice in the ACA era.

OCT 31, 2014

ESSENTIAL PSYCHOPHARMACOLOGY Director: Charles DeBattista, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) provide an update on recent advances in psycopharmacology of major disorders; 2) discuss in detail approaches to the treatment of specific disorders; 3) review recent studies on pharmacogenetics; 4) provide a rational basis for selection of medications; and 5) discuss efficacy and side effects of antipsychotic agents. SUMMARY: Psychopharmacology remains a mainstay of psychiatric treatment. This course reviews recent advances in the treatment of a number of common disorders. In addition to formal presentations, case examples will be employed and there will be question and answer periods.

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use for opioid dependence treatment. In addition, other areas pertinent to office based treatment of opioid dependence will be included in the seminar (e.g., nonpharmacological treatments for substance abuse disorders, different levels of treatment services, confidentiality). Finally, the seminar will utilize case-based, small group discussions to illustrate and elaborate upon points brought up in didactic presentations.

FINDING YOUR IDEAL JOB IN PSYCHIATRY Directors: Wesley E. Sowers, M.D., Robert S. Marin, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) describe factors impacting career choices and the personal economics of psychiatrists; 2) develop a life vision and a strategic plan for career development that is consistent with it; and 3) negotiate an employment contract that will support their life vision and personal priorities. SUMMARY: This session will enable graduating psychiatric residents and early career psychiatrists to effectively envision a career they would find personally satisfying and fulfilling as a first step in finding their first job or changing positions. It will describe the health care environment with both the opportunities and challenges it presents. It will use interactive discussion and practical exercises to enable participants to articulate a life vision and an ideal career profile. Having accomplished this, participants will be engaged in a consideration of how job searches have typically been conducted by unprepared applicants and will identify many of the pitfalls that can be avoided by well-informed applicants who prepare adequately. The evaluation of potential employers and effective strategies for doing so will be considered along with strategies for negotiating a job description that is consistent with career goals and desired lifestyle. The session will provide ample opportunities for participants to discuss their particular questions and concerns, and will provide exposure to senior psychiatrists who have created careers that have been highly satisfying and in balance with a rich personal life. it will emphasize the necessity of taking care of one's self in order to provide optimal care to persons to be served.

NOV 01, 2014

RECOVERY-ORIENTED CARE IN PSYCHIATRY Directors: Wesley E. Sowers, M.D., Annelle Primm, M.D., M.P.H. Faculty: Jacquelyn Pettis, M.S.N., R.N. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify principles of integrated, trauma-informed, culturally appropriate recovery oriented care for people with mental health and/or substance use conditions and other complex issues; 2) recognize benefits of a recovery approach for people working toward recovery as well as psychiatrists; and 3) apply practical strategies and tools to implement recovery oriented practices in the clinical setting. SUMMARY: This session provides a basic understanding of recovery from mental illness and substance use disorders and recovery oriented care. Seminar delivery includes lecture, discussions, and case studies and uses a collaborative teaching approach between a psychiatrist and a personal with lived experience which models the necessary collaborative therapeutic relationship that is essential for the delivery of optimal mental health care. This session was developed by the APA in collaboration with the American Association of Community Psychiatrists as part of SAMHSA's Recovery to Practice Initiative (RTP) to broaden and increase awareness, acceptance, and adoption of recovery principles and practices among mental health professionals.

BUPRENORPHINE AND OFFICE-BASED TREATMENT OF OPIOID USE DISORDER Directors: John A. Renner Jr., M.D., Petros Levounis, M.A., M.D. Faculty: Andrew J. Saxon, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify the clinically relevant pharmacological characteristics of buprenorphine; 2) list at least five factors to consider in determining if the patient is an appropriate candidate for office-based treatment with buprenorphine; and 3) describe the resources needed to set up office-based treatment with buprenorphine for patients with opioid. SUMMARY: The purpose of the seminar is to provide information and training to participants interested in learning about the treatment of opioid dependence, and in particular physiccians who wish to provide office based prescribing of the medication buprenorphine for the treatment of opioid dependence. Federal legislative changes allow office based treatment for opioid dependence with certain approved medications, and Food and Drug Administration (FDA) approved buprenorphine for this indication. The legislation requires a minimum of eight hours training such as the proposed seminar. After successfully completing the seminar, participants will have fulfilled the necessary training requirement and can qualify for application to utilize buprenorphine in office-based treatment of opioid dependence. Content of this seminar will include general aspects of opioid pharmacology, and specific aspects of the pharmacological characteristics of buprenorphine and its

CULTURALLY APPROPRIATE ASSESSMENT REVEALED: THE DSM-5 OUTLINE FOR CULTURAL FORMULATION: CULTURAL FORMULATION INTERVIEW WITH VIDEOTAPED CASE VIGNETTES Directors: Russell Lim, M.D., Francis G. Lu, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) describe methods to elicit the cultural conceptualizations of distress after a discussion of the different types of explanatory models and viewing a videotaped vignette; 2) describe interviewing techniques to assess the various aspects of cultural identity after assessing their cultural identity, and viewing videotaped interview.; 3) describe methods to elicit the stressors and supports as well as cultural features of vulnerability and resilience of a patient by using a focused developmental and social history; and 4) discuss and identify ethno-cultural transference and countertransference after discussing a journal article and viewing videotaped vignettes of patients and therapists experiencing both phenomenon. SUMMARY: Being able to perform a culturally appropriate assessment is a skill required by current RRC Accreditation Standards, including the ACGME core competencies and milestones for 2

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all graduating psychiatric residents. In addition, the Institute of Medicine's (IOM) report, "Unequal Treatment," showed that patients belonging to minority populations received a lower level of care than mainstream patients, when matched for income, insurance status, age, severity of illness. A culturally appropriate assessment can reduce mental health disparities by improving the quality of care provided to minority and underserved groups, improving their engagement, diagnosis, and treatment outcomes. There are many tools that can be used for a culturally appropriate assessment, such as the DSM-5 Outline for Cultural Formulation (OCF), and the Cultural Formulation Interview (CFI), and various mnemonics. The DSM-5 OCF and CFI are excellent tools for the assessment of culturally diverse individuals. Both provide a framework to assess cultural identity, cultural conceptualizations of distress, psychosocial stressors and cultural features of vulnerability and resilience, the clinicianpatient relationship, and overall cultural formulation. The seminar will also present Hay's ADDRESSING framework for assessing cultural identity, Arthur Kleinman's eight questions to elicit an explanatory model, and the LEARN model used to negotiate treatment with patients. Attendees of the seminar will learn how to assess their own and their patient's cultural identities, and how the ethnicity and culture of the clinician and patient affects transference and counter transference. The seminar will teach clinicians specific skills for the assessment of culturally diverse patients. Participants will participate a small group exercise on their own cultural identities, and then will view mini lectures on the five parts of the DSM-5 Outline for Cultural Formulation, and the corresponding questions from the Cultural Formulation Interview, as well as instruction on interview skills, supplemented by the viewing of taped case examples. Discussion of the case vignettes will enable attendees to gain an understanding of the skills demonstrated in the videotaped vignettes. Participants will be encouraged to share their own approaches, and then modify their approaches based on material presented in the seminar. Clinicians completing this seminar will have learned interviewing skills, including the use of the DSM-5 OCF and CFI, useful in the culturally appropriate assessment, differential diagnosis, and treatment planning of culturally diverse patients.

magnetoencephalography brain imaging of 2 yogic breathing techniques (one for treating OCD and its inactive control correlate) will be presented along with other novel studies in mind-body medicine based on yogic concepts and techniques. Participants will practice and learn to implement select disorder- and condition-specific meditation techniques for inducing a meditative state, "energizing," facing mental challenges, one specific for OCD, a breathing technique for generalized anxiety disorders, a 3-minute technique to help manage fears, an 11-minute technique for anger, a 3-minute technique to help focus the mind, 2 different meditation techniques specific for depression (one for 11 minutes and the other for 15 minutes), an 11-31 minute technique for addictions, a 11 minute technique for ADD/ADHD, one for releasing childhood anger, and one useful for PTSD and other traumatic events. Participants will also be taught how to formulate short protocols for patients that want to include these techniques in their treatment protocol as either a complement to medication, medication resistance, or electing to forgo medication. Complete protocols will be taught for OCD, ADHD, PTSD, and major depressive disorder. Ample time will be given to answer questions and to discuss the participant's personal experiences of the techniques during the seminar. Participants will be sitting in chairs. No prior experience with yoga or meditation is necessary.

FRONTIERS IN CLINICAL WORK WITH PEOPLE WHO ARE HOMELESS Director: Stephen M. Goldfinger, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of this course, the participant should be able to: 1) demonstrate an understanding of the interactions and history of mental illness, poverty, substance abuse and homelessness; 2) provide social, psychological and structural interventions to improve the lives and functioning of individuals who are homeless and mentally ill; and 3) identify five ways to more successfully help individuals receive housing and entitlements. SUMMARY: This training course will bring together many of the national leaders who provide mental health services to individuals who are homeless and have serious mental illnesses, organize these services, or do research on issues affecting this population. We who are involved love this work, and our goal is to encourage more mental health professionals to work with people who are homeless with serious mental illnesses and with the organizations that provide services and support to this population. The format will include a combination of formal presentations, clinical consultations, and interactive panels; clinicians, academics, consumers, residents, and policymakers. Participants will also have the opportunity to discuss strategies with their colleagues across disciplines and gain a deeper understanding of diverse approaches to dealing with people who are homeless and have mental illnesses.

KUNDALINI YOGA MEDITATION TECHNIQUES FOR ANXIETY DISORDERS INCLUDING OCD, DEPRESSION, ADHD, AND PTSD Director: David Shannahoff-Khalsa, B.A. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) teach others specific meditation techniques for treating OCD, anxiety disorders, depression, grief, fear, anger, addictions, PTSD, and ADHD; 2) understand published results showing efficacy for new and treatment refractory OCD and OC spectrum disorders and comorbid patients; and 3) understand novel yogic concepts and techniques in mind-body medicine now published in peerreviewed scientific journals. SUMMARY: Two clinical trials will be presented that used Kundalini yoga meditation techniques specific for treating OCD. The first is an open trial with a 55% improvement on the Y-BOCS (International Journal of Neuroscience 1996) and the second is a RCT (CNS Spectrums 1999) with a 71% mean group improvement on the Y-BOCS. Whole-head, 148-channel

PRIMARY CARE SKILLS FOR PSYCHIATRISTS Directors: Erik R. Vanderlip, M.D., Lori E. Raney, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the causes of excess mortality in the SMI population and discuss lifestyle modifications that are 3

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useful; 2) understand the current state of the art in treating diabetes, hypertension, dyslipidemias, smoking cessation and obesity; 3) develop skills in understanding the use of treatment algorithms for chronic illnesses; 4) explore the use of a primary care consultant to assist in treatment of patients if prescribing desired; and 5) discuss the rationale for psychiatrist prescribing with emphasis on liability and scope of practice concerns. SUMMARY: Patients with mental illness, including those with serious mental illness (SMI), experience disproportionately high rates of tobacco use, obesity, hypertension, hyperlipidemia and disturbances in glucose metabolism. This is often partially the result of treatment with psychiatric medications. This population suffers from suboptimal access to quality medical care, lower rates of screening for common medical conditions and suboptimal treatment of known medical disorders such as hypertension, hyperlipidemia and nicotine dependence. Poor exercise habits, sedentary lifestyles and poor dietary choices also contribute to excessive

morbidity. As a result, mortality in those with mental illness is significantly increased relative to the general population, and there is evidence that this gap in mortality is growing over the past decades. Because of their unique background as physicians, psychiatrists have a particularly important role in the clinical care, advocacy and teaching related to improving the medical care of their patients. As part of the broader medical neighborhood of specialist and primary are providers, psychiatrists may have a role in the principal care management and care coordination of some of their clients because of the chronicity and severity of their illnesses, similar to other medical specialists (nephrologists caring for patients on dialysis, or oncologists caring for patients with cancer). There is a growing need to provide educational opportunities to psychiatrists regarding the evaluation and management of the leading cardiovascular risk factors for their clients. This seminar provides an in-depth, clinically relevant and timely overview of all the leading cardiovascular risk factors which contribute heavily to the primary cause of death of most persons suffering with SMI.

Innovative Programs INNOVATIVE PROGRAM 1

and the strategies and challenges involved with its implementation. This will be followed by a discussion with the panelists. References:

THE EFFECTS OF TRAUMA: A REVIEW OF THE ADVERSE CHILDHOOD EXPERIENCES STUDY AND THE IMPLEMENTATION OF TRAUMA INFORMED CARE

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Chair: Lawrence Malak, M.D. Presenter: Dawn Griffin, Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to understand: 1) specifics of the ACE Study and the findings on Medical and Mental Health in adults; 2) background on trauma informed care; and 3) implementation of trauma informed care at county level. SUMMARY: The effect and prevalence of traumatic events in the lives of those with psychiatric disorders has long been known to be greater than general population. However the extent of those effects in both psychiatric and medical condition had not been well defined. The Adverse Childhood Experiences Study is an ongoing collaborative, multi-site study looking at the effect of adverse childhood experiences on many aspects of adult health. The study has looked at over 17,000 patients at multiple sites and has been led by Dr. Felitti and Dr. Anda. There have been numerous results produced from this study highlighting a link between increased medical issues and mental health issues in those with significant ACE scores. Those with an ACE have an increased risk for smoking, obesity, HIV/AIDS, suicide attempts and alcohol abuse, among other findings. As we have become increasingly aware of the effects of trauma, shift towards Trauma Informed Care has taken hold. It's principles center on acknowledging and trauma and its impact on the whole person on their way to recovery. Dr. Griffin is implementing Trauma informed care in the San Diego County system, focusing on integrated care and examining all aspects of care through a trauma lens. The presentation will start with background of the ACE studies and presentation of the results, followed by background on Trauma informed care

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http://acestudy.org/home Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, et al. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine. 1998; 14:245-258. Felitti VJ, Anda RF. The Relationship of Adverse Childhood Experiences to Adult Health, Well-being, Social Function, and Health Care. Chapter 8 in The Effects of Early Life Trauma on Health and Disease: the Hidden Epidemic; Editors: Lanius R, Vermetten E, Pain C. Cambridge University Press. 2010 Felitti, V. & Anda, R. (2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behavior: Implications for healthcare. In R. A. Lanius, E. Vermetten, & C. Pain, Eds., The hidden epidemic: The impact of early life trauma on health and disease. Cambridge University Press. NY: Cambridge University Press. van der Kolk, B, McFarlane, A, & Weisaeth, L. (2007). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: The Guilford Press.

INNOVATIVE PROGRAM 2

GAMBLING: FROM IMPULSE CONTROL TO NONSUBSTANCE ADDICTION: EPIDEMIOLOGY, NEUROBIOLOGY, DIAGNOSIS AND TREATMENT Chair: Vishesh Agarwal, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) improve awareness among psychiatrists, psychotherapists and other clinicians about gambling disorder for early identification and intervention; 2)educate about identification and diagnosis of gambling disorder; 3) educate and discuss available resources for treatment of gambling disorder. SUMMARY: Background: Pathological gambling was added to the DSM in 1980. The DSM-5 renamed it as "Gambling Disorder" and 4

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placed it with "Substance-Related and Addictive Disorders." It is the only "behavioral addiction" in this group. This was done for good reason. Research has shown association of gambling disorder with other medical, psychiatric and social problems. More and more scientific literature has revealed the commonalities between gambling and substance-use disorders. Purpose: To educate and discuss about the pathology, diagnosis and treatment options of gambling disorder. Methods: Literature review from PubMed and data reviewed from the American Gaming Association (AGA), National Council on Problem Gambling (NCPG), Center for Gaming Research and other sources. Results: Since 1975, the proportion of adults who have never gambled has dropped from 1 in 3 to 1 in 7. An estimated 4% of US adult population meets criteria for problem gambling. Some form of legalized gambling exists across all states of United States except Hawaii and Utah. The total revenue generated from all forms of gambling is close to $100 billion, which is higher than all other major forms of entertainment combined. Annual social costs related to gambling disorder are estimated at $7 billion. Diagnosis and treatment: Unlike substance use disorders, gambling disorder does not have a laboratory test and routine screening is not common. Various screening tools are available including South Oaks Gambling Screen (SOGS), Gambling Symptom Assessment Scale (G-SAS) and Gambling Addiction Index (GAI), but they are not frequently used and there is limited evidence on their validity and reliability. Various psychosocial approaches have been studied and evidence varies on their success. Cognitive therapy, behavior approaches and motivational interviewing have shown good evidence; others such as 12 step approach, self-help groups Gamblers Anonymous (GA) and self exclusion have also been found to be useful. There is no FDA approved pharmacological treatment and little evidence exists on some agents that have been studied. Conclusion: Gambling disorder is a serious addiction and its prevalence appears limited because it may present as a co-morbid illness. The magnitude of this disorder is not clearly defined as routine screening is not performed. The limited treatment options available need to be further studied.

tise required to meet their needs, but its implications for the deaf and hard of hearing has not been extensively studied. Community Behavioral Health, a community mental health center in the Eastern Shore of Maryland, has collaborated with the Core Service Agency to obtain telepsychiatry equipment for the deaf and hard of hearing with the assistance of an HRSA grant from Gallaudet University. This innovative equipment utilizes the assistance of a social worker from Arundel Lodge who is culturally competent in American Sign language. This workshop will explain the role of a clinician in obtaining, creating, and managing logistical necessities to allow effective delivery of mental health services to the deaf and hard of hearing in rural regions. OCT 31, 2014 INNOVATIVE PROGRAM 3

CET (COGNITIVE ENHANCEMENT THERAPY): AN EBP THAT IMPROVES SOCIAL COGNITION, VOCATIONAL SUCCESS AND PHYSICAL HEALTH Chair: Ray Gonzalez, M.S.W. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the critical role that neuroplasticity and cognitive remediation play in the recovery process; 2)recognize the importance of treating cognitive deficits (processing speed, working memory, executive functioning) and social cognition in persons with schizophrenia, bipolar disorder and depression; 3) state the theoretical constructs underlying CET and why CET as a one-time intervention has shown to be very durable (improvements maintained at 12+ years) with 85% attendance and graduation rates; 4) Discuss how CET can increase physical health in a Health Home by improving cognitive functioning of persons recovering from mental illness so they can be better primary care patients;5) Explain how CET, with its emphasis on increasing social cognition and awareness of work place norms can facilitate vocational success, especially job retention. SUMMARY: There are very few truly active treatment programs to help individuals with a diagnosis of schizophrenia or bi-polar disorder in their recovery process. Most treatment/services are maintenance programs. Since 2001, CET (Cognitive Enhancement Therapy), a SAMHSA recognized Evidence Based Practice form of cognitive remediation, has been successfully disseminated to 27 sites in ten states. During 48 once-a-week sessions of computer exercises, social cognition groups and individual coaching, over 1,000 clients have learned how to be socially wise and vocationally effective. CET groups average 85% attendance and graduation rates during the year-long treatment process. CET connects with stable patients like no other treatment program and has demonstrated increased medication compliance. Attendees will learn how CET promotes recovery by participating in a typical CET session including specialized computer exercises; a social cognition talk followed by completing and discussing homework questions; and completing an interactive cognitive exercise. A PowerPoint talk will describe the neuroscience research supporting CET; the social, vocational and educational effectiveness of CET; using CET with a wide range of individuals (adults, Transitional Aged Youth, persons with high- level autism); and how CET is effective with person from diverse ethnic and socio-economic back-

A CLINICIAN'S GUIDE TO CREATING A TELEPSYCHIATRY PROGRAM FOR THE DEAF AND HARD OF HEARING Chairs: Suni N. Jani, M.D., M.P.H., Sheena Patel, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) recognize the needs of the deaf and hard of hearing in a mental health evaluation; 2)identify rural regions with underserved populations of deaf and hard of hearing mental health patients; 3) understand how to acquire specialized telepsychiatry equipment for the deaf and hard of hearing; 4) understand how to manage specialized telepsychiatry equipment for the deaf and hard of hearing; and 5) understand future possibilities and implications for research in telepsychiatry for the deaf and hard of hearing. SUMMARY: Telepsychiatry has been recently approved for some Medicaid and state-funded services to people who have mental health, developmental disabilities as well as substances abuse needs or difficulties. It is a well-established and wellstudied method of delivering behavioral health services to individuals who do not have ready local access to the exper5

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Support Worker, will present data on the program's Community Support Worker peer support position including details on the peer training experience and impact of the Community Support Worker role. The panel will conclude by providing an overview on new hepatitis C treatments and implications for mental health support and psychiatric care of patients undergoing hepatitis C treatment now and in the future. Case discussions will be used to initiate the large group discussion. Copies of program materials will be disseminated during the symposium.

grounds. This presentation will demonstrate the hope and practical wisdom that CET offers including how acceptance and adjustment to a psychiatric disability can improve physical health, independence, vocational effectiveness and social cognition. Lessons learned from disseminating CET to a wide range of sites ranging from freestanding clinics to state hospital to large mental health centers will be presented.

MANAGING PSYCHIATRIC ILLNESS AND HEPATITIS C: COMMUNITY PROGRAMS AND INTERVENTIONS TO OVERCOME SUBSTANCE USE AND PSYCHOSOCIAL BARRIERS

EXPANDING ACCESS TO TRANSGENDER SURGERIES TO LOW INCOME PATIENTS: LESSONS FROM IMPLEMENTATION FOR MENTAL HEALTH AND PRIMARY CARE PROVIDERS

Chair: Shannon Taylor, R.N. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify gaps in psychosocial care of marginalized patients with hepatitis C; 2)apply strategies to support the mental health needs of people living with hepatitis C and/or undergoing treatment, including: group therapy, peer support, and psychiatric management by specialists; and 3) understand the benefits of a multi- disciplinary approach to psycho-social support for patients with hepatitis C. SUMMARY: Mental health and substance use issues have historically been significant barriers for treating patients with hepatitis C, especially in tertiary care settings. These requirements have limited hepatitis C treatment to only a select group of patients with tri- morbidity (psychiatric illness, substance use and hepatitis C). The latest hepatitis C treatment guidelines recommend interdisciplinary models of care that employ harm reduction principles and which research has documented can achieve comparable hepatitis C treatment response rates to patients without active substance use. The recent addition of novel hepatitis C treatments have further complicated drug regimens and have placed greater emphasis on hepatitis C adherence and the need for improved patient engagement in overall physical and psychosocial treatments. This session will provide participants with an overview of the barriers to and recent advances in Hepatitis C care, focusing on the gaps in psychosocial care of marginalized patients with hepatitis C. The symposium will focus on a collaborative hepatitis C care model, called the Toronto Community Hep C Program (TCHCP), an interdisciplinary, community- based, harm reduction model of hepatitis C treatment and support for people with serious mental health issues and/or ongoing substance use. The anchor of the TCHCP is a group psycho-education program that supports patients with multiple psychiatric and physical co-morbidities. Based upon research and evaluation data from the TCHCP, we will present four research papers (published or under review). The symposium will begin with an overview of the TCHCP model and the core interprofessional programs offered to patients treated in this multi-site model. Dr. Susan Woolhouse will present retrospective data on hepatitis C treatment outcomes and qualitative data illustrating how group structure and cohesion facilitated behavioural change. Ms. Zoe Dodd, Group facilitator, will present data on group psychotherapy outcomes, including a summary of key group therapy factors unique to this group. Dr. Sanjeev Sockalingam will present on the role of psychiatrists in this integrated model and will report on hepatitis C and psychiatric outcomes for patients with severe mental illness and active substance use. Robert McKay, Community

Chairs: Dan H. Karasic, M.D., Julie Graham, M.Sc. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand principles of mental health assessment of transgender patients for surgery, in accordance with the Standards of Care 7 of the World Professional Association for Transgender Health; 2)appreciate psychosocial issues of concern in assessment and preparation for transgender surgeries for low income patients in public health settings; 3) understand benefits and risks of medical and surgical transition-related care for transgender patients; 4) understand key challenges in developing transgender care programs in community mental health and primary care settings. SUMMARY: In 2013, the San Francisco Department of Public Health implemented a program to provide medically necessary transgender surgeries to low income patients under Healthy San Francisco (a program for those otherwise uninsured) and MediCal. This expansion of access will be implemented statewide in 2014, with the expansion of MediCal under the Affordable Care Act, and with the State of California's mandate that MediCal (as well as private insurance) cover these procedures. Recognizing that patients in its public medical and mental health clinics requiring surgery have psychosocial needs that must be addressed to assure optimal outcomes, an interdisciplinary team of medical and mental health providers, social workers, administrators, and transgender health advocates have devised protocols and educational programs for providers and patients. This workshop will discuss this innovative program, and principles of assessment and preparation for transgender surgery for low income patients in community mental health and primary care settings. INNOVATIVE PROGRAM 4

CLOSING THE QUALITY GAP: IMPROVING QUALITY OF CARE FOR PATIENTS WITH SERIOUS MENTAL ILLNESS THROUGH A PROVIDER-DRIVEN CARE DELIVERY DESIGN Chairs: Sonia Tyutyulkova, M.D., Ph.D., Jennifer B. Greenspun, L.C.S.W., M.S. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) At the conclusion of this session, the participant should be able to describe a participatory, consensus6

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trains peers to provide supportive services to people with psychosis and learn to work with clinicians. SUMMARY: Parachute NYC, a Medicaid demonstration grant where peers and providers use Intentional Peer Support (IPS) and Needs Adapted Treatment Model (NATM) to inform crisis services that provide opportunities for people to stay in their lives and recover. IPS is a peer developed model that encourages peers to use relationships to gain new perspectives that enable them to support and challenge each other to grow. NATM, a flexible individualized approach widely used in northern Europe, engages the person in crisis and his/her networks in a dialogic process from which problems and solutions organically emerge. Parachute offers a confidential, peer-operated support line providing mutual understanding for anyone in a stressful situation; clinician/peer mobile teams (adapted from NYC's mobile crisis teams) providing a home visit within 24 hours of crisis referral using NATM to offer treatment as often as needed for up to one year; and peer/professional crisis respites where people not at imminent risk can stay and remain connected to their daily lives when they need more support than home can provide. Services are voluntary and any NYC adult resident may use any or all components. Full service continuity is available. We will describe system, clinician and peer implementation perspectives and early research findings.

building, provider-driven approach to quality improvement; 2)At the conclusion of this session, the participant should be able to describe a systemic approach to quality improvement for patients with serious mental illness; 3) At the conclusion of this session, the participant should be able to recognize the importance of provider and peer engagement in the design and implementation of quality initiatives. SUMMARY: We will present and discuss the quality improvement initiative of a large community mental health system providing a continuum of services to individuals with serious mental illness. We will describe an innovative care delivery model designed using a bottom-up, provider-driven process. In an organization-wide effort to improve the quality of care for the population we serve, we formed a workgroup to develop recommendations for improvement. The workgroup had an agency-wide representation from: a) different disciplines (psychiatry, nursing, social work, case management, employment specialist, residential coordinator, psychiatric rehabilitation staff, peer specialist); b) programs (Assertive Community Treatment, residential services, vocational and psychiatric rehabilitation programs); c) different geographic locations; d) management level (direct care staff, mid-level management, executive level). The task before the workgroup was to develop an "ideal" model of care that will improve the outcomes for patients with serious mental illness. A framework centered around quality and around the following concepts was used to guide the workgroup discussion: a) the fundamental source of quality is in the person's experience; b) quality is made or lost in the relationship with a provider; c) a continuous healing relationship is a central element of quality; d/ care organized around patient's needs. We used a participatory, consensus building, deliberative process, including agency-wide feedback on the model the workgroup developed. We will discuss the "ideal" care delivery design developed by the workgroup and some of the barriers to implementation that we identified. The "ideal" system of care we envisioned is consistent with the principles of lean design and culture, a quality improvement approach focused on increasing value and decreasing waste. We will describe the implementation of an appropriate organizational infrastructure to support the model. We will discuss the potential of the model to improve the effectiveness, efficiency, safety, timeliness and person-centeredness of care. We will examine the implications of a bottom-up, provider- driven approach for successful implementation and sustainability, and its potential advantages over top- down, policy-driven models.

INNOVATIVE PROGRAM 5

INCREASING ACCESSIBILITY TO CARE FOR RETURNING VETERANS: DELIVERING VA SERVICES ON A COLLEGE CAMPUS Chairs: Ellen Herbst, M.D., Keith Armstrong, L.C.S.W., Brandina M. Jersky, M.A., Bridget Leach EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify common psychiatric and medical diagnoses observed in Veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND); 2) recognize challenges with treatment engagement and retention of OEF/OIF/OND Veterans in traditional models of VA mental health care; 3) learn about an innovative model of mental health treatment delivery on a college campus that reduces barriers to care and promotes treatment engagement among OEF/OIF/OND Veterans. SUMMARY: Over two million men and women have served in Operations Iraqi Freedom (OIF), Enduring Freedom (OEF), and/or New Dawn (OND). The Post-9/11 GI Bill greatly expanded educational benefits for these Veterans, resulting in over a million former service members enrolling in higher education programs. Returning Veterans are at risk for a number of psychiatric and physical problems, including PTSD, depresssion, anxiety, substance use disorders, chronic pain, and mild traumatic brain injury (mTBI). Treatment retention rates of OIF/OEF/OND Veterans in traditional VA Medical Centers are low. Given the need to provide care to a rapidly growing population of returning war Veterans, the development of innovative approaches to reduce barriers to care, and thus improve treatment delivery, is imperative. The San Francisco VA Medical Center, in collaboration with City College of San Francisco (CCSF), developed a program to conduct outreach to student Veterans, enroll student Veterans in VA health care, deliver empirically validated

CRISIS AS OPPORTUNITY: HOW PARACHUTE NYC INTEGRATES PROFESSIONALS AND PEERS TO IMPROVE OUTCOMES FOR MENTAL HEALTH CRISES Chairs: David C. Lindy, M.D., Mary Jane Alexander, Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the Needs Adapted Treatment Model (NATM), its conceptual origins, its literature, and the ways it has been adapted by Parachute NYC; 2) appreciate the three components of Parachute NYC (confidential, peer-operated support line, clinician/peer mobile treatment teams, peer/ clinician respite services) and how they interact; 3) understand the Intentional Peer Support (IPS) model and how it 7

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and outside the agency, such as Care Coordination and Network Providers. The Call Center is data driven and strives to provide the highest quality of customer services to the mentally ill. Call Center staff are trained in crisis response, motivational interviewing, customer services, and technology based training. We track and trend call data on a daily basis. Currently, the Call Center telephone responsiveness includes having an 3-4 seconds average speed of answer with a live voice; 98% of calls answered within 30 seconds; and a call abandonment rate of only 1.8%. In a continuous effort to use data generated by the Call Center services to improve care of the mentally ill, new initiatives are tested and put into practice quarterly. Some of these include identifying the Military/ Veteran and Traumatic Brain Injury (TBI) population to ensure proper coordination of care; development of a peer support telephone queue line; and the recruitment of bilingual staff as an additional enhancement to an already well diverse Call Center.

mental health treatment, train faculty and administrative staff on Veterans' issues, and provide social work and care coordination services, all on the CCSF campus. Initiated in the fall of 2010, the CCSF Veterans Outreach Program has delivered VA services to over 1100 student Veterans and enrolled over 370 Veterans in VA health care, providing treatment that easily accessible and driven by student Veterans' needs. We will describe the need to expand this type of program and provide a conceptualization and replicable model of care for student Veterans on college campuses across the country.

INNOVATIONS IN MENTAL HEALTH CARE THROUGH PSYCHIATRIC CALL CENTER SERVICES: HOW WE CREATED A DATA DRIVEN 24/7 RESPONSE SYSTEM FOR THE MENTALLY ILL Chairs: Venkata Jonnalagadda, M.D., Victoria Jackson, L.C.S.W., M.S.W. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) explain the need for a 12 County 24/7 mental health call center and how it has evolved into a data driven state of the art service program; 2)explain the organizational team structure and logistical operations of a 24/7 mental health call center; 3) discuss essential call center training to effectively and efficiently respond to the needs of the mentally ill; 4) explain how a 24/7 call center is a continuous data driven best care model for identifying unseen needs, improving internal services, and advocating for mental health services needed in the community; and 5) discuss future initiatives for enhancements of a mental health call center. SUMMARY: Eastpointe is a Managed Care Organization (MCO) in the state of North Carolina that manages, coordinates, and monitors the mental health, intellectual /developmental disabilities, and substance use/addiction (MH/IDD/SA) services in a 12 county region. Eastpointe has been identified as a 1915 (b) (c) Medicaid Waiver site in the state of North Carolina. A waiver is an agreement between the state and Center for Medicaid Services in Washington to be exempted from certain Medicaid rules. A waiver is necessary for the state to enter into managed care contracts because of the transfer of risk (of losing money) from the state to a Managed Care Organization. It requires the MCO to have an adequate risk reserve. It requires the Managed Care Organization to provide organizational functions found in a typical health insurance plan such Management of the Provider Network, Quality Management, and Utilization Management. We authorize payment for Medicaid services for residents who need MH/IDD/SA services and whose Medicaid originates in the Eastpointe region. We authorize payment for statefunded services for residents without Medicaid or private insurance who live in the Eastpointe region. We monitor the quality of services consumers receive, and handle consumer concerns and grievances. We provide a toll-free Member Call Center number for members (individuals within the 12 county region) to access 24 hours a day, 365 days a year. The Member Call Center is one of the key components of the Managed Care Organization. The Call Center is responsible for facilitating access to all supportive, clinical and informational services for members or on behalf of the members within the Eastpointe catchment area. The Call Center collaborates closely with other management areas within

A MODEL FOR COMPREHENSIVE CRISIS SERVICES IN A METROPOLITAN AREA Chair: Edgar K. Wiggins, M.H.S. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) At the conclusion of this workshop, participants will be able to identify the essential components of a comprehensive community crisis service; 2)At the conclusion of this workshop, participants will be able to discuss the advantages and limitations of the Baltimore City model for crisis services; 3) At the end of this workshop, participants will be able to discuss the role that this model has with intervening with individuals in a suicidal crisis; 4) At the end of this workshop, participants will be able to identify the role that the Baltimore City model has with effectively diverting individuals from psychiatric inpatient care. SUMMARY: Baltimore Crisis Response, Inc. (BCRI) has been providing community based mental health crisis services since 1993. Initially implemented as a pilot project, BCRI has expanded over time to include a full range of crisis intervention services including a 24 hour telephone hotline, mobile crisis teams, residential crisis beds and in-home services. Designed to be part of the public mental health system, BCRI provides services in the least restrictive setting possible without consideration of the individual's ability to pay. In 2005, BCRI was recognized as one of the three model crisis programs nationwide. In 2008, The Maryland Disability Law Center and the Center for Public Representation published a report entitled "Maryland Citizens in Psychiatric Crisis, A Report: Improving Emergency Department and Community Care for People with Psychiatric Disabilities." In this report the state of Maryland was encouraged to replicate the model of service delivery provided by BCRI. The strength of the BCRI model is its full range of services centrally located in one entity. This results in a uniform standard of care that is often lacking in decentralized and fragmented services. It also makes for a more efficient use of resources and allows for patients to move within the service system should their clinical picture change. This session will review each service system component of the BCRI model, including the data for each component. There will also be a review of the treatment scope, levels of care protocol, admission criteria, and high risks issues. Additional discussion will describe the 8

2014 INSTITUTE ON PSYCHIATRIC SERVICES

challenges of providing services to a population with a significant incidence of co-occurring disorders. In addition there will be a discussion of the specific applications of the model with regard to patients presenting with a range of psychiatric symptoms, concerns, and crises. This presentation will also discuss and describe additional specialized services provided within the scope of this model including: Results of an eight year police training project (developed utilizing the National CIT Model), Public education efforts (utilizing cable and public access television), Response to critical incidents, and Debriefing and postvention. Finally, there will be review of the data collected over the past six years related to a hospital diversion initiative.

that our community psychiatry practice site offers students and residents a unique practice environment that promotes patient-centered care with an interdisciplinary educational approach.

LESBIAN, GAY, BISEXUAL, AND TRANSGENDER MENTAL HEALTH TRAINING: A NEW PARADIGM FOR DEVELOPING CLINICAL EXPERTS Chairs: Weston S. Fisher, M.D., Ellen Haller, M.D., Erick K. J. Hung, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) appreciate why specialized training is needed to meet the needs of patients with specific socio-cultural backgrounds; 2) describe the multiple steps taken by one academic residency program in its development of specialized training in LGBT mental health; 3) develop ideas for designing similar specialized training opportunities at their home institutions including active discussion of the challenges and opportunities. SUMMARY: Many Lesbian, Gay, Bisexual and Transgender (LGBT) people have unique mental health issues and needs. In response to the critical need for leaders in LGBT mental health, the UCSF Adult Psychiatry Residency Training Program developed an LGBT Mental Health Area of Distinction. The primary purpose of this specialized training experience is to prepare interested residents for careers as leaders in LGBT Mental Health. Participating residents are required to rotate through specific clinical rotations, review an LGBT knowledge base, develop scholarly projects, and present educational material to near peer learners. The steps taken in developing this specialized Area of Distinction can be used as a model for other training programs wishing to offer similar opportunities. Participants in this workshop will be led through the process of needs assessment, identifying currently existing opportunities, building a team of collaborators, identifying core learning objectives and curricular requirements, and concretizing a final product.

NOV 01, 2014 INNOVATIVE PROGRAM 6

INTERPROFESSIONAL COLLABORATION AND EDUCATION IN COMMUNITY PSYCHIATRY Chairs: Kelly Gable, Pharm.D., Mirela D. Marcu, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) Define interprofessional education in the context of community mental health; 2)Describe an example of a collaborative practice agreement between a psychiatric clinical pharmacist and community psychiatrist; 3) Discuss the implementation of interprofessional education among pharmacy and medical students and residents in a community mental healthcare setting. SUMMARY: Assertive Community Treatment (ACT) is an evidence-based practice best described as a community mental health treatment model designed for patients with severe and persistent mental illnesses. ACT teams consist of a multidisciplinary team of providers that include: a psychiatrist, social workers, substance abuse specialists, vocational specialists, nurses, and peer support specialists. ACT has become a standard of care in community psychiatry since the movement of deinstitutionalization, yet it is often not offered as an experiential learning site for medical students and residents. This program will provide an example of how a psychiatric clinical pharmacist and community psychiatrist have developed a collaborative practice agreement that allows for both clinicians to effectively provide psychiatric services on two full-fidelity ACT teams. A psychiatric clinical pharmacist is a pharmacist that specializes in the field of psychiatry, often including post-graduate education in psychiatric medicine. Such collaborative agreements are newer to the field of psychiatry and vary based on individual state laws. This is the first of its kind in the state of Missouri. Both clinicians also have academic appointments at schools of pharmacy and medicine, respectively. Their academic affiliations allow for forth year pharmacy students, first year pharmacy residents, third and fourth year medical students, and third year psychiatry medical residents to be directly incorporated into their ACT services. Due to the intensive nature of ACT services, students and residents have the opportunity to provide care out in the community at patients' apartments, shelters, and group homes. This program will describe multiple examples of interprofessional education that include daily treatment team involvement, review of patient treatment plans, psychopharmacology discussions, and psychiatric patient assessments. We believe

CULTURAL DIVERSITY DAY: A RESIDENT INITIATIVE COMBINING CULTURE, EDUCATION, AND ACTIVISM Chairs: Kathleen M. Patchan, M.D., Ellen Lee, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) demonstrate understanding of the importance of culturally informed training for psychiatry residents, using the DSM-5 as a resource; 2) understand the background leading to the University of Maryland cultural psychiatry program, specifically Cultural Diversity Day; and 3) discuss challenges and implement practical tools for residents, faculty, and training directors to develop similar programs in their home institutions. SUMMARY: Cultural competency is essential in treating people with psychiatric disorders. This is demonstrated by the fact that the DSM 5 has an entire section devoted to culturally specific formulation. Further, the ACGME requires all psychiatry residency programs to offer didactics on sociocultural topics and to teach residents to be culturally sensitive and work with patient from diverse backgrounds, Nevertheless, many residency programs do not provide comprehensive 9

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culturally-sensitive programs. In 1993, a diverse group of psychiatry residents at the University of Maryland School of Medicine perceived a need for examining cultural issues in psychiatry. This was prompted by growing tension among American and international medical graduates and a perceived lack of sensitivity towards diverse populations. This led to the creation of the University of Maryland/ Sheppard Pratt Residency program's first Cultural Diversity Day (CDD). The program has become a popular and novel event that is developed each year by residents in collaboration with the Residency Training Office. Since its inception 20 years ago, the CDD has evolved into a full day training opportunity to learn about and discuss culturally-relevant and often controversial issues that have long-standing impact. Eminent public speakers around the country have lectured on relevant topics that have implications both nationally and abroad. Most recently, programs have discussed the stigma of mental illness, the interaction of culture and poverty, the perspective of mental health in Middle Eastern culture, and the role of military culture on mental health. Earlier topics have included Latino cultures,

multiracial identity; women's issues; and gay, lesbian, and bisexual communities. The upcoming CDD will discuss immigration with a focus on acculturation, parent- child issues, substance abuse, and suicide. The majority of funding is provided by the training department but funding is also provided by fellowship grants such as the, APA/SAMHSA Minority Fellowship Program awarded to individual residents. This resident-driven event has been well-received by the clinical community and has broadened the perspective on cultural issues throughout the residency program and Department of Psychiatry. The program has also garnered widespread institutional support and has been attended by faculty and residents from other departments, the hospital community, the student body, and the general public.. The role of this workshop is to discuss the evolution of CDD, discuss challenges, and to provide comprehensive, yet practical, tools for other residency programs to develop culturally diverse events in their home institution. Cultural sensitivity will become increasingly important as the DSM continues to evolve and psychiatrists continue to work with and advocate for patients from diverse populations.

Forums OCT 30, 2014

contact with any of his family, and though he seems gregarious and happy in many respects, he is also isolated and distressed in other ways. Other than the warmhearted people who leave food next to his shopping cart in the mornings, he is not currently connected with any community services. Aaron was an active boy growing up, following in his father's footsteps and playing baseball throughout his childhood. After he was arrested for unusual behavior in his late teens, he slowly isolated himself from his family and friends, and became fixated on the belief that there was an impending alien invasion. As his thoughts became more and more troubling, he ended up living in the woods of Northern California while his father tried unsuccessfully to reach out for help and to avoid the violent tragedy that would eventually make national headlines. Psychosis causes some individuals to reach for care and connectedness with others, while other people tend to isolate and fall through the cracks. The narratives of this latter group are frequently lost and are the focus of this film. By highlighting the human aspects of psychosis while also addressing the controversial issue of violence and untreated severe mental illness, Voices captures a uniquely human, honest and raw glimpse of lives which are frequently confined to the shadows of society. www.VoicesDocumentary.com

VOICES: A DOCUMENTARY FILM ABOUT HUMAN AND UNTOLD STORIES OF PSYCHOSIS Chairs: Gary Tsai, M.D., Rachel Lapidus, M.D., M.P.H. Presenter: Hiroshi Hara EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) better recognize and understand the issue of stigma in mental health through film; 2) better recognize and understand the challenges of family members of individuals impacted by serious mental illness; and 3) recognize and identify the role of psychiatrists in advocacy and improving mental health systems, and how media such as film can be a powerful medium for mental health advocacy. SUMMARY: Voices is a feature length documentary that tells the compelling personal stories of three individuals from very different backgrounds, all of whom are connected by their experiences with psychotic mental illness. In this state in which reality is bendable and oftentimes frightening, the resulting behaviors and its life impact are often misunderstood and incomprehensible. As a result, the human side of the psychotic experience is often lost. Born into a privileged family in Vietnam and pursuing her education in Switzerland, Sharon was a beautiful, humble woman with a gentle nature. After meeting her husband abroad, she immigrated to California and began to hear derogatory voices and show signs of paranoia and depression. As a newly arrived immigrant, she was diagnosed with schizophrenia. Struggling to support her in any way they could, her family's unbreakable bond and loving perseverance were tested in their long journey to find her care. Thomas is an active member of his community, well-liked and frequently greeted by those he walks by in his neighborhood. Kind and cheerful, he enjoys Chinese food and going to church. He has also been homeless and living on the streets of San Francisco for the past 15 years. Originally from Ohio, he is no longer in

HERE ONE DAY: A FILM ABOUT BIPOLAR DISORDER AND SUICIDE Chair: Kathy Leichter EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand and reflect upon the universality and multifaceted nature of suicide; and 2) understand the ways in which individuals and families can overcome stigma and bridge isolation pre- and post-vention. SUMMARY: When filmmaker Kathy Leichter moved back into her childhood home after her mother's suicide, she discovered a hidden box of audiotapes. Sixteen years passed before she 10

2014 INSTITUTE ON PSYCHIATRIC SERVICES

had the courage to delve into this trove, unearthing details that her mother had recorded about every aspect of her life from the challenges of her marriage to a state senator, to her son’s estrangement, to her struggles with bipolar disorder. Here One Day is a visually arresting, emotionally candid film about a woman coping with mental illness, her relationships with her family, and the ripple effects of her suicide on those she loved. Here One Day is reducing stigma and isolation, raising awareness, linking individuals and families to support, and helping to change mental health and suicide prevention and postvention policy across the country. By film’s end Leichter wanted audiences to be left with a complex interaction of human beings. She wanted mental illness to feel more real, as if it could happen to any of us. She wanted suicide to feel less a sensationalized drama, for it too happens to so many, from all ethnicities and backgrounds. Most importantly, She wanted to portray a family, like so many others, trying to do its best under difficult circumstances, far from torn asunder, yet fundamentally transformed.

able to: 1) understand the various types of biases minority group members have confronted historically while; examining the societal implications of marginalization; 2) define and identify microaggressions while recognizing the psychological costs to both the victims and; perpetrators; and 3) appreciate the personal steps each individual can take to redress microaggressions in mental health care. SUMMARY: The primary aim of this symposium is to survey the progress that minorities in psychiatric training have made in the last 50 years. Appreciating history is imperative to shaping the future as it helps us to avoid missteps of the past and to honor those that paved a smoother road for us. However, it is not enough to simply note the difference between yesterday and today as we still have many improvements to make within our own training programs. As such, we will also discuss ways to take action in order to move in the right direction and achieve our goals. The first session will feature Dr. Donna M. Norris, co-editor of Women in Psychiatry: Personal Perspectives (2012), and Dr. Orlando B. Lightfoot, one of five authors of the landmark AJP article, "Problems of Black Psychiatric Residents in White Training Institutes" (1970). The two trailblazers will graciously share their experiences as psychiatrists-in-training and early career psychiatrists during a time of few minority psychiatrists. In the second session, four APA members-in-training will share their experiences of marginalization in residency. Of course, no history lesson would be complete without a discussion of the future. Dr. Ranna Parekh, co-author of Overcome Prejudice at Work (2012), will close the session with words of empowerment, explaining the value of being aware of microaggressions acts that infringe upon someone's time, energy, space and mobility and how to develop strategies, gain perspective, and optimize one's frustration tolerance when confronting insults, microaggressive acts, and prejudice.

OCT 31, 2014

SERVING THE SAME POPULATIONS: COLLABORATING FOR BETTER OUTCOMES Chair: Saul Levin, M.D., M.P.A. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand one’s distinct professional role within alternative comprehensive, cooridinated care models; and 2) identify practical collaborative/team-building strategies for providing quality care and improving outcomes. SUMMARY: This forum addresses the multitude of issues concerning how best psychiatrists and social workers can work together in different settings and with different populations as we adapt to new health care delivery systems and new funding mechanisms. Specifically discussed will be integration of health and behavioral health care, with primary care integrated into behavioral health settings or behavioral health integrated into primary care settings; the focus on quality and outcomes; strategies for effective team practice; the importance of prevention and early intervention; person and family-centered care. Additional discussion will focus on the psychosocial issues that need to be more fully addressed in order to reduce hospitalizations and concerns regarding the high use of psychotropic medications in foster care and in long term care.

HOW TO CREATE AN INTEGRATED TELEHEALTH PSYCHIATRIC SERVICE PROGRAM FOR RURAL MH POPULATIONS Chairs: Michael Farnsworth, M.D., Sara Emich EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify the technical, administrative, and clinical challenges in delivering high quality, cost effective, efficient telehealth mental health services to rural SPMI consumers in the face of mental health provider shortages; 2) understand current practice standards, reimbursement requirements, and basic technical information on telehealth systems; and 3) set up a basic telehealth system to provide remote access to patients. SUMMARY: Recruitment and retention of mental health practitioners into rural practices is an enormous challenge. This workshop details how 10 counties in South Central Minnesota responded to the needs of their spmi consumers by creating a technologically savvy, integrated mental health model that combines psychiatry, mid-level practitioners and cloud based EMR into a telehealth network which has pleased both consumers and practitioners. Practical information on the technical, administrative and clinical use of telehealth will be provided.

TRAINING EXPERIENCES OF MINORITY INDIVIDUALS IN PSYCHIATRY: THEN, NOW, AND HOW TO CREATE THE BEST FUTURE Chairs: Andrea M. Brownridge, J.D., M.D., M.H.A., Stacia E. Mills, M.D. Presenters: Orlando B. Lightfoot, M.D., Donna M. Norris, M.D., Frank Clark, M.D., Tiffani L. Bell, M.D., Cynthia Moran, M.A., M.D., Ranna Parekh, M.D., M.P.H. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be

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NOV 01, 2014

NOV 02, 2014

INTEGRATING CARE IN UNDERSERVED COMMUNITIES: WHAT'S POVERTY GOT TO DO WITH IT?

THE CIVIL RIGHTS MOVEMENT AND AFRICANAMERICAN MENTAL HEALTH Chair: Altha Stewart, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) the role physicians, especially psychiatrists, in adviancing civil rights, and 2) understanding of how the Civil Rights Act of 1964 impacted the health and emotional wellbeing of African Americans. SUMMARY: The period from 1945 to 1954 represents a uniquely negative period for civil rights of Black Americans and severely limited advances that supported improved health and mental health care for Blacks. The Civil Rights Movement encompassed social movements whose goals were to end racial segregation and discrimination against Black Americans and to secure legal recognition and federal protection of the citizenship rights in the constitutional amendments adopted after the Civil War. During the Civil Rights Movement, physicians (including psychiatrists) and other health care workers gave aid to civil rights workers, provided a ‘medical presence’ to deal with the physical and psychological aftermath of the attacks and violence, and mobilized the health professions to get involved in the movement. Panelists will share their personal stories and professional experiences and perspectives to illustrate the significance of the passage of the Act then and the legacy of that impact on the mental health and emotional well-being of African-Americans today.

Chairs: Derri Shtasel, M.D., M.P.H., Mark Viron, M.D. Presenters: Derri Shtasel, M.D., M.P.H., Sarah MacLaurin, N.P., Joanna D'Afflitti, M.D., M.P.H., Joseph Joyner, M.D., Mark Viron, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) describe the challenges of integrating primary and behavioral health care for patients living in poverty, includeing uniquely marginalized populations; 2) compare and contrast the challenges between community health centers and community mental health centers in addressing care integration in impoverished communities; and 3) identify opportunities and challenges for young providers tasked with leading change initiatives in Community Health Centers and Community Mental Health Centers. SUMMARY: The benefits of integrating primary care with behavioral health care are very promising, and different models have been described that address weighting the primacy of medical vs. psychiatric illness (1), structures of integration (2) and the influence of payment reform on care redesign (3). The roles of poverty and of the social determinants of health add further complexity to these models, and require enhancements of accepted integration approaches (4). Both Community Health Centers (CHC's) and Community Mental Health Centers (CMHC's) serve patients with multiple chronic disorders, many of whom are economically disadvantaged, socially marginalized and have problems beyond the capacity of a simple dyadic medical transaction. In community health settings, standard collaborative care models require socio-cultural adaptations to in order to be successful (5). Both settings face challenges in funding, infrastructure, and culture, though staff and patient characteristics often differ. Adding yet one more degree of complexity are patients who are "outsiders" to the "usual" socioeconomically disenfranchised group of patients seen in community settings—immigrants and refugees. This group's needs may warrant unique modifications to alreadyenhanced models of care integration. Early career primary care and psychiatry providers tasked with leading change within their organizations will present their approach to care integration at a CHC and at a CMHC. Case vignettes will be used to illustrate challenges and potential solutions specific to these settings and the underserved communities with whom they work. 1.

2. 3.

4.

5.

EXCELLENCE IN MENTAL HEALTH ACT Chair: Joseph J. Parks, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) Understand two methods in gaining access to prospective payments; 2) Understand the history of the various approaches; and 3) Discuss the comparisons. SUMMARY: Innovation in payment methodology is a key strategy of the Affordable Care Act. Payment methodologies play a key role in realizing the goals of behavioral health parity, integration between behavioral health and primary care, improved access to care, and improved quality of care. This session will present two methods by which Community Mental Health Centers are gaining access to prospective payment methodology. First through the two-year demonstration project offered in the newly passed Excellence in Mental Health Act and second by becoming Federally Qualified Health Centers. This session will present the history of these different approaches, compare their differences in detail, and discuss the impact on psychiatrists, consumers, and public payers of behavioral healthcare. The session will begin with an overview of the history of payments to CMHC's and FQHC's and the current volume of services they provide. Second presentation will cover the excellence in mental health act. The third presentation will present the experience of C MHC's becoming FQHC's. This will be followed by a panel presentation by Representative Matsui-and author of the excellence in mental health act, federal and state officials, C MHC representative, and psychiatrist and consumer perspectives. The session will and with 30 minutes of audience Q&A with panel discussion.

Mauer, BJ. 2006. Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence- Based Practices. National Council for Community Behavioral Healthcare Blount, Alexander. Families, Systems, & Health, Vol 21(2), 2003, 121-133. Colleen L. Barry, Ph.D., M.P.P. Beyond Parity: Mental Health and Substance Use Disorder Care under Payment and Delivery System Reform in Massachusetts. Blue Cross Blue Shield of Massachusetts Foundation, 2011. Proser, M., and L. Cox. 2004. Health Centers' Role in Addressing the Behavioral Health Needs of the Medically Underserved. Special Topics Issue Brief #8. Washington, DC: National Association of Community Health Centers, Inc Ell K, Kayton W, Cabassa L, Xie B, Lee P. Kapetanovic S, Guterman J. Depression and Diabetes Among Low-Income Hispanics: Design Elements of a Socio-Culturally Adapted Collaborative Care Model Randomized Controlled Trial. Int J Psychiatry Med. 2009; 39(2):113132.

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Lectures OCT 30, 2014

trists can provide leadership in collaborative care programs, and review the implementation of such evidence-based programs in a range of different health care settings.

SMOKING AND MENTAL ILLNESS: A WAKE UP CALL FOR PSYCHIATRISTS Lecturer: Jill Williams, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the correlation between smoking and mental illness; 2) understand the numerous consequences of tobacco use on health, quality of life, employment and community integration; and 3) understand the barriers that prevent psychiatrists from intervening for tobacco use and ways to increase access to care. SUMMARY: Thank you for your interest in our division. Our website is full of information about our research team, educational activities, current research projects and clinical trials. We hope you will explore our website and find the information provided helpful. Following the release of the U.S. Surgeon General’s Advisory Committee Report on Smoking and Health in 1964, tobacco use has become the basis of an ever expanding area of clinical research. This report stated that tobacco use is a cause of lung cancer and laryngeal cancer in men, a probable cause of lung cancer in women and the most important cause of chronic bronchitis. We now know that tobacco use is the most common preventable cause of death and that about half of the people who don't quit smoking will die of smoking-related problems. Recent data reveals that people with serious mental illness die, on average, 25 years earlier than the general population. Under the direction of Jill M. Williams, MD, the Division of Addiction Psychiatry, Rutgers Robert Wood Johnson Medical School, is committed to tobacco and substance abuse research, training and education.

RECENT ADVANCES IN THE GENETICS AND GENOMICS OF AUTISM SPECTRUM DISORDERS Lecturer: Matthew State, M.D., Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) demonstrate a knowledge of the rationale for gene discovery in autism spectrum disorders; 2) demonstrate a knowledge of the important role of new (de novo) mutation in the risk for neurodevelopmental disorders; 3) demonstrate a knowledge of the similarities and differences between what has been recently learned regarding the genetics of autism and the genetics of schizophrenia. SUMMARY: It is an extraordinarily exciting time for the genetics and translational neuroscience of autism spectrum disorders (ASD). Advances in genomic technologies and the availability of large-scale study cohorts are leading to a rapidly expanding list of ASD genes and risk regions. These recent successes are presenting the field new challenges in conceptualizing how to translate genetic data into an actionable understanding of pathophysiology. This presentation will review recent progress in gene discovery in ASD, focusing on the particular role of new (de novo) variation as well as the overlap in genetic risks for a wide range of neurodevelopmental disorders, including autism and schizophrenia. The challenges presented by the tremendous degree of genetic heterogeneity that has been uncovered will be considered. Finally, the implications of continued success in gene discovery for clinical care will be considered.

COLLABORATIVE CARE: MAKING A DIFFERENCE IN THE AGE OF ACCOUNTABLE CARE

GRIEF: DIAGNOSTIC AND TREATMENT FORMULATION PROBLEMS

Lecturer: Jurgen Unutzer, M.A. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the clinical and business case for integrated behavioral health care; 2) understand evidencebased clinical approaches to providing collaborative mental health care; and 3) implement evidence-based collaborative care programs in diverse health care settings. SUMMARY: Only about 2 in 10 adults living with a diagnosable mental health condition will see a psychiatrist or a psychologist in any given year. The Affordable Care Act will dramatically increase the number of adults who will have insurance coverage for behavioral health care, but our current delivery system is already at capacity. Collaborative Care is an evidence-based approach for psychiatrists to partner with primary care providers to dramatically improve the lives of the millions of adults who do not have access to effective mental health specialty care today. Over 80 randomized controlled trials have demonstrated that collaborative care is more effective for common mental health disorders than usual care. This presentation will review the clinical and the business case for collaborative care, discuss how psychia-

Lecturer: Mardi Horowitz, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) demonstrate knowledge of the DSM-V diagnoses that may suit post loss symptomatic responses; 2) demonstrate knowledge of the formulation of what is likely to progress to resolution without treatment and what may need facilitation to progress after a seemingly pathological response to bereavement; and 3) demonstrate knowledge of how therapy techniques might vary with persons who are bereaved and with various levels of identity and relationship functions before the loss. SUMMARY: Loss comes as a shock to most people, even those who have had a period to anticipate the death of a loved one. Such events occur in the midst of life stressors, social supports, and pre-existing levels of personality function, as well as possible psychiatric disorders. The clinician often has to make an initial evaluation in a single extended session. Diagnoses range across several categories, and an important DSM 5 change from DSM-4 is to include bereavement as a possible situation within diagnoses of Major Depressive 13

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Disorders. This talk will cover the distinctions between normal and pathological courses through mourning. An emphasis on formulation beyond diagnoses will include discussion of the necessary complexities. Level of personality function is one of these complexities, requiring some inference as to what is a regression under the trauma of loss, and what may have been the person’s optimum level of functioning before the loss. Implications for treatment by psychotherapy assignments will be discussed.

appreciate the critical new roles for behavioral health care services and public service community psychiatry in the emerging health care system; and 3) be able to describe a proactive, progressive agenda for the necessary growth and development of public service psychiatry. SUMMARY: Psychiatry is in a distinct moment in history. The multiple challenges facing our society have given impetus, contested though it is, to the redesign of the way our nation delivers health care. But is there room for psychiatryt? This lecture will first describe the present circumstances and the particular predicament—the fiery bed, or perhaps couch—that community psychiatry is in, before outlining a way forward toward a revolutionary agenda of creative reengagement with public service by a profession on fire. The lecture will end with a discussion of the myriad implications of such a profound reorientation on public policy, practice, our profession and our underlying theories about psychiatric challenges.

ALONE WE CAN DO SO LITTLE; TOGETHER WE CAN DO SO MUCH: ADDRESSING GENERAL AND SPECIAL POPULATION MENTAL HEALTH NEEDS THROUGH INNOVATIVE COLLABORATIONS Lecturer: Laura Roberts, M.D. EDUCATIONAL OBJECTIVES: At the conclusion of the session, the participant should be familiar with: 1) epidemiological data concerning mental health and its impact, including suicide, felt in the general population 2) epidemiological data concerning mental health and its differential impact, including suicide, felt in specific subpopulations 3) several innovative academiccommunity collaborations who conduct inspired work to improve understanding and health outcomes in relation to very difficult mental health and well-being issues in the community SUMMARY: Mental disorders and related conditions are common and devastating for their impact, whether viewed in relation to individual suffering or broad consequences for global health. Special populations, such as young people, elders, minority, and veterans, often carry greater burdens in terms of disability and premature mortality. Misunderstanding, prejudice, societal and scientific neglect contribute to these grave concerns. The problems are so immense that they cannot be addressed by efforts, even very heroic efforts, undertaken in isolation. Collaboration amongst partners who are attuned, deeply committed, and highly innovative can make a difference in improving health of the general population and special populations most at-risk for mental health issues and suicide. Academic medicine is entrusted with advancing the well-being of all people, now and in the future, through work across five interdependent missions of advancing science, educational excellence, clinical innovation, community engagement, and leadership and policy efforts. AcademicCommunity partnerships focused on specific health issues of immense concern can bring about inspiring, unexpected, and positive results. In this talk I present examples of extraordinary partnerships to improve the well-being of special populations, to prevent suicide, and to create greater understanding of many of the hardest issues we face in caring for people living with mental illness and related conditions.

IMPLEMENTING FIRST EPISODE PSYCHOSIS SERVICES: POLICY ISSUES Lecturer: Howard H. Goldman, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the structure and content of firstepisode psychosis services; 2) understand the history of policy barriers to implementing first-episode psychosis services; and 3) understand current policy changes, includeing the Affordable Care Act, that will enhance implementtation of first-episode psychosis services. SUMMARY: This presentation will review the policy history of firstepisode psychosis services in the United States. The original Community Mental Health Centers program emphasized early interventions in mental disorders, but the treatment technology did not live up to the promise of preventing disability related to schizophrenia and other psychotic disorders. The focus of the public mental health system shifted to individuals who were already disabled and who had the greatest impairment and functional limitation. In addition, the system increasingly has been financed by Medicaid. The main source of Medicaid eligibility for adults has been through receipt of disability benefits from the Supplemental Security Income program. As a result, firstepisode psychosis became a lower priority for services. The rise of the recovery movement increased optimism for a range of interventions that might be applied earlier in the course of a psychotic disorder. New interventions have stimulated policy changes to support implementing firstepisode services in the United States, including the Affordable Care Act with its expansion of Medicaid for nondisabled adults.

OCT 31, 2014

IS OUR BED ON FIRE OR IS IT US? COMMUNITY PSYCHIATRY AND HEALTH CARE REDESIGN Lecturer: Kenneth S. Thompson, M.D. EDUCATIONAL OBJECTIVES: At the conclusion of the session, the participant should be able to understand: 1) understand the fundamental redesign of health services contained in the Affordable Care Act; 2) 14

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methods for taking care of themselves while continuing to be effective in their professional roles; 4) learn more about teaching methods that are evidence-based and effective alternatives to traditional lectures, involving interactive and smaller group discussion formats; and 5) consider more active involvement in trying to prevent global warming and other major environmental hazards and catastrophes, recognizing that this represents a major public mental health intervention. SUMMARY: A general review of what he sees as the important directions for our profession to orient itself in order to be more effective and constructive. This will involve bridging the hopes of the past idealism of the community mental health movement with the current and future transformation of the health system. Can we be good clinical leaders and population focused collaborators with our medical colleagues while maintaining a vigilant recovery-oriented advocacy role in relation to the persons in whose care we participate. More importantly, can we do all this while maintaining a realistic focus on whether and how we can affect the upstream impacts (social determinants, cultural disparities, structural competencies, environmental stability) on our patients' and our communities' health and well-being. Is it any more realistic for us to think that we can do this now than it was when we began this idealistic odyssey 40-50 years ago?

CHALLENGES AND OPPORTUNITIES: BEHAVIORAL HEALTH IN AN ERA OF HEALTH REFORM Lecturers: Pamela Hyde, J.D., Elinore F. McCance- Katz, M.D., Ph.D. EDUCATIONAL OBJECTIVES: At the conclusion of the session, the participant should be able to understand: 1) the roles and functions of the Substance Abuse and Mental Health Services Administration (SAMHSA); 2) the collaborative relationships between SAMHSA and psychiatry; and 3) SAMHSA's role in behavioral health and primary care integration and programs in behavioral health workforce development initiatives. SUMMARY: Forthcoming.

VIOLENCE AND MENTAL ILLNESS: RESEARCH, RISK ASSESSMENT AND MHCS Lecturer: Renee L. Binder, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify the association between mental illness and violence; 2) perform a violence risk assessment; and 3) recognize the benefits of mental health courts. SUMMARY: Throughout history, people with mental illness have been thought to be at higher risk for violence and this has led to stigmatization and discrimination. Modern studies have researched whether this association is valid and under what circumstances. These studies need to be interpreted cautiously in terms of differing definitions of violence, differing definitions of mental illness, questions about the reliability of sources of data and differing comparison groups. The data shows that most persons with mental illness are not violent and that most violent acts are not committed by persons with a serious mental disorder. Various factors increase or decrease the risk of violence and these factors need to be considered when doing violence risk assessments. Mental health courts have been established throughout the United States as one type of intervention for people who suffer from mental illness and have committed crimes. Studies have shown that these courts can reduce criminal recidivism and violence.

HEARING VOICES IN THREE CULTURES: A COMPARISON WITH IMPLICATIONS FOR RECOVERY Lecturer: Tanya Luhrmann, Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand that auditory hallucinations associated with psychosis often have different content and meaning in different cultures; 2) recognize that not all hallucinations are associated with psychosis; and 3) understand different techniques to manage auditory hallucinations associated with psychosis. SUMMARY: We still know very little about whether and how the auditory hallucinations associated with serious psychotic disorder shift across cultural boundaries. This paper presents the first interview-based research to compare auditory hallucinations across three different cultures. An anthropologist and several psychiatrists interviewed twenty people in San Mateo, California; Chennai, India; and Accra, Ghana who heard voices and met the inclusion criteria of schizophrenia about their experience of voices. We found that American subjects were more likely to use diagnostic labels and to report violent commands than subjects in Chennai and Accra. We found that subjects in Chennai and Accra were more likely than the Americans to report rich relationships with their voices and less likely to describe the voices as the sign of a violated mind. These observations suggest that the voicehearing experiences of persons with serious psychotic disorder are shaped by local culture. These differences may have clinical implications. The paper also presents an account of hallucination-like events in the general population.

DOING THE COMMUNITY WALTZ: A SAGING AND RAGING TRIP WITH THE WALTS (I.E., WHITMAN TO WHITE), WITH VISITS TO KELLY AND CRONKITE ON THE WAY Lecturer: David A. Pollack, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify several key developments in the evolution of community/public psychiatry since the inception of the community mental health era in the us, especially those that are most relevant for the future; 2) recognize areas of health care in which psychiatric practice that community/public psychiatrists (and other behavioral health providers) can and should be participating and leading; 3) demonstrate effective

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NOV 01, 2014

SENSITIVE PERIODS IN BRAIN DEVELOPMENT: UNMASKING HOW LIFE EXPERIENCE CONFERS RISK FOR PSYCHIATRIC ILLNESS

FIREARMS AND VIOLENCE: IMPLICATIONS FOR INDIVIDUAL AND POPULATION HEALTH

Lecturer: David A. Lewis, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) recognize the normal developmental trajectories of cognitive functions; 2) identify the developmental changes in brain circuits that underlie the maturation of these functions; and 3) recognize the vulnerability of these developmental trajectories to environmental events occurring during sensitive periods. SUMMARY: The identification of individuals at high risk for a major psychiatric illness, and the development of novel intervenetions that can change the course of the illness before its debilitating clinical features emerge, are critical current challenges in public health. These challenges are particularly important for schizophrenia, a leading cause of years of life lost to disability and premature mortality in developed countries. Schizophrenia is now considered to be a neurodevelopmental disorder in which psychosis actually represents a late, and potentially preventable, outcome of the illness; that is, the appearance of the diagnostic clinical features of schizophrenia (psychosis) represents not the onset of the illness, but the downstream product of years of pathogenic processes at work. From this perspective, the development of effective preemptive treatments for schizophrenia (i.e., interventions that modify disease pathogenesis in order to prevent or delay the appearance of psychosis) requires knowledge of 1) the abnormalities in brain circuitry that underlie the core functional disturbances of the illness, 2) when during the course of development these abnormalities in brain circuitry arise, 3) how life experiences influence the appearance of these altered neural circuits, and 4) means to detect these abnormalities in brain circuitry when their functional impact is still subclinical. This presentation will review the current evidence supporting the ideas that 1) impairments in certain cognitive processes are the core feature of schizophrenia, 2) these cognitive impairments reflect abnormalities in specific cortical circuits, and 3) these circuitry abnormalities arise during childhoodadolescence. For example, both excitatory and inhibitory components of prefrontal cortical circuitry undergo marked developmental changes in molecular content, structural features and electrophysiological properties. Many of these changes are protracted, persisting through adolescence, but the rate and timing of the changes are distinctive to specific circuit components. This constellation of developmental trajectories likely provides the neural substrate for the maturation of cognitive abilities that are dependent on prefrontal circuitry, and also suggests the presence of multiple developmental epochs when circuit components may be particularly sensitive to adverse experiences, such as use of cannabis. The implications of these findings for the development and implementation of safe, preemptive, disease-modifying interventions in individuals at high risk for a clinical diagnosis of schizophrenia will be discussed.

Lecturer: Garen J. Wintemute, M.D., M.P.H. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to understand: 1) the epidemiology of firearm violence in the United States and the major individual and population risk factors for involvement in firearm violence; 2) the principal policies governing firearms in the United States; and 3) the effectiveness of some of the most widespread policy- and practice-based efforts to prevent firearm violence. SUMMARY: This research-based presentation will review the epidemicology of interpersonal and self-directed firearm violence in the United States. A brief review of firearm design and performance will be included. Particular attention will be given to historical trends, personal and population risk factors, firearm policies, and prevention efforts. We will take a critical approach, identifying widespread misconceptions about firearm violence and strengths and weaknesses in the current body of research evidence. We will consider an agenda for- and obstacles to-future research and prevention efforts.

FROM COUCH TO CAMERA: THE REFLECTIONS OF AN ACTIVIST PSYCHIATRIST Lecturer: Dee Mosbacher, M.D., Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) demonstrate knowledge of the dialectics of activism and psychiatry; and 2) demonstrate knowledge of the role of activism in a psychiatrist's life. SUMMARY: Dee Mosbacher, M.D., Ph.D., is a psychiatrist and Academy Award-nominated documentary filmmaker. Her activist academic career began in the 1970s when she earned a doctorate in social psychology with a thesis that compared the medical model of schizophrenia with the psychoanalytic model, which was the prevailing view at that time. Subsequently, while at Baylor College of Medicine, Mosbacher was propelled into further political action when a sign saying "KILL THE QUEERS" was taped to the locker of a gay classmate. She co-produced (with Joan Biren) Closets are Health Hazards: Gay and Lesbian Physicians Come Out! While Mosbacher served on the board of the American Medical Student Association, this video was distributed to medical schools throughout the United States and abroad. During her residency at Harvard Medical School, Dr. Mosbacher disagreed with the psychiatric establishment over the most effective way to conceptualize and treat schizophrenia. She advocated patient and family education about the biological etiology of the illness, eschewing psychodynamic concepts such as the schizophrenogenic mother. As an out lesbian, Mosbacher also opposed the psychoanalytic institute policy of refusing to admit LGBT candidates. While a resident, she produced the video, Lesbian Physicians on Practice, Patients, and Power, which portrays lesbian physicians and medical students as practitioners and recipients of healthcare. This video has been distributed internationally. After moving to San Francisco with her spouse Dr. Nanette Gartrell, Dr. 16

2014 INSTITUTE ON PSYCHIATRIC SERVICES

Mosbacher worked in the public sector as Medical Director for Mental Health in San Mateo County. In addition, Mosbacher volunteered for organizations supporting patients with HIV/AIDS and for clinics treating chronically mentally ill homeless people. In 1991, Dr. Mosbacher coproduced and directed (with Frances Reid) the Academy Award- nominated film, Straight from the Heart, a documentary that explores relationships between straight parents and their lesbian and gay children. Since then Mosbacher has produced and/or directed another seven films and one Web campaign under the auspices of Woman Vision, a nonprofit she formed in 1993 to promote equal treatment of all people through the use of educational media.

THE NYU PSILOCYBIN CANCER PROJECT Lecturer: Stephen Ross, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to understand: 1) the prevalence and spectrum of psychological distress in patients with advanced or terminal cancer; 2) the link between spirituality and psychological distress in patients with advanced or terminal cancer; and 3) the biological and psychosocial rationales for a novel psychopharmacolgic-psychosocial treatment paradigm, consisting of psilocybin-assisted psychotherapy, to treat psychological and existential distress in patients with advanced or terminal cancer. SUMMARY: Advanced or terminal cancer is associated with significant psychological distress including and most notably depresssion, hopelessness, suicidal ideation and behaviors, generalized anxiety, existential distress, and death anxiety. There is a known link between spiritual states and psychological distress in patients with advanced or terminal cancer diagnoses, whereby increased intrinsic spiritual states are considered buffers against depression, hopelessness and a hastened desire for death. Several spiritually and existentially-oriented psychotherapies have been developed over the last decade to target diminished spiritual states, provoked by a diagnosis of a grave cancer diagnosis. Also, in the last decade there has been a renewed interest in the use of hallucinogen treatment models within psychiatry to treat a range of psychiatric conditions, including the constellation of psychological distress in patients with advanced or terminal cancer. Since 2008, the NYU Psilocybin Cancer Project has administered a moderate single dose of psilocybin to 30 participants in a double-blind placebocontrolled trial to explore the potential efficacy of psilocybin-assisted psychotherapy in patients with advanced cancer and psychosocial distress. We hypothesize that psilocybin administration in combination with existentially oriented psychotherapy can diminish psychological and spiritual/existential distress in individuals with advanced cancer. Preliminary clinical observations and an interim analysis of data will be presented, in which a majority of patients experienced acute and sustained reductions in general anxiety, existential distress, and depression, as well as increased in spiritual states and practices.

EMBRACING AND EXPANDING THE SCIENCE OF RECOVERY Lecturer: Lisa B. Dixon, M.D., M.P.H. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) how to recognize different definitions of recovery and how they overlap and differ; 2) how to recognize that shared decision making supports recovery; and 3) how to recognize that peer delivered services support recovery. SUMMARY: The provision of care that is recovery oriented has become an imperative for mental health services. However, a lack of understanding and clarity about how to define and understand recovery has impeded progress toward the delivery of recovery oriented care. This talk will explore different ways to conceptualize recovery as well as the validity and unique aspects of SAMSHA’s definition as distinct from traditional research definitions of recovery. The talk will also consider how the use of shared decision-making and peer-delivered ser-vices support the new conceptualization of recovery.

POPULATION CARE MANAGEMENT BY CMHC HEALTH HOMES Lecture Chair: Joseph J. Parks, M.D. Lecturer: Joseph J. Parks, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to understand: 1) the Clinical Outcomes of Missouri CMHC Health Homes; 2) the Health services Utilization Outcomes of Missouri CMHC Health Homes; and 3) the Financial Outcomes of Missouri CMHC Health Homes. SUMMARY: Missouri implemented CMHC Health Homes in January 2012. This lecture will present detailed perfomance outcomes after 2 years in operation. CMHC Health Homes were designed to provide integrated person centered care to persons with serious mental illness with multiple chronic medical illness by providing data driven, care management, care coordination, and preventive care. Missouri CMHC health Homes have added nurse care managers and primary care physician consultants to the traditional CMHC teams which have been trained to facilitate and support their clients general medical needs. Persons in Missouri CMHC have had signification improvement in health outcomes, reductions in hospital utilization and overall reduction in total healthcare costs.

IMPROVING QUALITY: THE KEY TO HIGH PERFORMING MENTAL HEALTH SYSTEMS Lecturer: Nick Kates, M.B.B.S. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the dimensions of high quality care and IHI´s Triple Aim and identify where their system may be underperforming; 2) use a simple 5 step approach to introducing improvements in their service; 3) understand how to use the consumer's experience to assist in redesigning services; and 4) apply the Improvement Model and PDSA rapid cycle improvements. SUMMARY: Increasingly changes in mental health care systems are driven by the desire to improve the quality, efficiency and safety of the care provided. This workshop will introduce participants to a series of practical tools and approaches for understanding how their system is performing in the 6 domains of quality mental health care patient-centerdness, 17

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timeliness, effectiveness, efficient, safe and equitable—and where there are opportunities for improvement, why these problems occur, and simple ways to introduce and sustain needed changes. It begins by summarizing what quality care, as defined by the National Institute of Medicine, is and outlines two frameworks for analyzing a system. The first is the UK's NHS Change model which looks at the 8 components of successful change in a system, beginning with building a common purpose and identifying effective leadership. The second is a simple 5 step approach for analyzing a system, identifying root causes of problems and introducing improvements. The workshop then introduces some of the basic tools of quality improvement work that can be used in any setting and describes how they can be used. These tools include ways to measure team performance: an analysis of how well core processes are working; building a process map; the 5 Whys and the Fishbone diagram to understand root causes; the Improvement model and rapid cycles of change (Plan Do Study Act or PDSA cycles); conducting a supply and demand analysis to improve access; and using the consumer / family experience as a way of redesigning services.

BLACKS AND AMERICAN PSYCHIATRY: AFTER 170 YEARS OF APA AND 50 YEARS OF CIVIL RIGHTS, WHAT'S NEXT? Lecturer: Altha Stewart, M.D. EDUCATIONAL OBJECTIVES: At the conclusion of the session, the participant should be able to: 1) provide a history of the evolution of American psychiatry beginning with the early works of the superintendents of mental institutions who founded the first association; 2) describe the role of APA in shaping psychiatry’s involvement in addressing the difficult issue of race and mental illness since 1844; and 3) provide a framework for the role of psychiatry and American psychiatrists in moving the field forward in the current racial climate and promote a more culturally competent environment for clinical services delivery, research and training of the next generation of psychiatrists. SUMMARY: It has been said that "the history of American psychiatry is the history of the American Psychiatric Association". [1][1] From its earliest days, psychiatry in American has struggled with how to deal with the racism that is at the core of relations between Blacks and Whites in this country. The APA began as the Association of Medical Superintendents of American Institutions for the Insane (later the American Medico-Psychological Association). The 13 founding members, at an early organizing meeting established a committee on ‘Asylums for Colored Persons’ which may represent the first efforts to address the race problem in the years before the Civil War. Since that time the history of the APA is filled with many stories of the challenges raised, many still unaddressed, as it relates to American psychiatry and African Americans. Over the last 50 years the APA’s history related to this interracial dynamic has been chronicled in many different ways. Books, articles (in scientific and lay journals), conferences and other modes of communication have raised questions regarding racism as a mental illness, the continued racial and ethnic disparities in the clinical arena, and concerns about misdiagnosis and research outcomes that result in inadequate and inappropriate treatment for Blacks continues to concern many in the African American community. This lecture will provide participants with an understanding of how the evolution of psychiatry and psychiatric practices in the US impacted the health and emotional well-being of African Americans over that same time period. The speaker will offer her perspective on how the APA can increase involvement of African Americans in the organization and the field and improve its relationship with the African American community to assure that advances in the field benefit this population. Reference:

MAD v. BAD: LINKING MENTAL HEALTH DISPARITIES AND PUBLIC HEALTH CONSEQUENCES Lecturer: William B. Lawson, M.D., Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) Understand the disparities in mental health and general health for African Americans, and other racial and ethnic minorities; 2) Discuss the social policies and how they exacerbate the problem; and 3) Learn to recognize the effects of the combinations of different behaviors. SUMMARY: The racial disparities in mental health and general health outcomes are well documented for African Americans and other racial and ethnic minorities. Part of the persistence of the problem is the failure to consider disturbing behavior in African American males as related to mental disorders or failure to believe that such the disorders are amenable to compassionate treatment. Confounding under recognition of mental disorders is the inability or unwillingness of many in the African American community to be thought of as mad vs. bad. Risk of arrest is valued over mental health treatment. Social policies such as deinstitutionalization and the war on drugs further exacerbate the disproportionately high incarceration and homeless rate. The incarceration further contributes to the spread of such diseases as HIV and hepatitis C into the general community. Interventions for former inmates are limited by the under recognition of mental and substance abuse disorders and by the substitution of self-treatment with drugs of abuse and other unhealthy behaviors. Failure to recognize the combination of the therapeutic effects combined with the euphoric effects of drugs of abuse and acceptance of bad vs. mad behavior further contributes to treatment failure. Comprehensive interventions at all levels of intervention are necessary to reduce these persistent disparities that imperil the survivor of African American males.

One Hundred Years of Psychiatry. Hall, JK (ed). Columbia University Press, New York, NY, 1944. The Formation of the Black Psychiatrists of America. Pierce, CM. In Racism and Mental Health, (eds) Willie et al, pp. 525-554, University of Pittsburgh Press.

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ance, functional capacity, brain activation, triggering positive responses in neuroplasticity, improved real- world functioning), and what types of concurrent interventions are most likely to lead to real world functional gains. Other issues of importance include how close these interventions are to being broadly or even universally deliverable and what standards of evidence would be required to determine efficacy and long term effectiveness of treatments aimed at cognition and functioning in schizophrenia.

HOW BIOMARKERS FOR PTSD WILL ADVANCE DIAGNOSIS AND TREATMENT Lecturer: Charles Marmar, M.D. EDUCATIONAL OBJECTIVE & SUMMARY: The Posttraumatic Stress Disorder (PTSD) Research Program at The New York University Langone Medical Center is committed to improving the diagnosis and treatment of PTSD. The program is currently studying the factors that promote risk and coping in PTSD. The factors studied include structure of functional imaging, genetics, endocrine, metabolic and proteomic biomarkers, and adverse health outcomes in PTSD. It is believed that this work will advance our understanding of PTSD and lead to more accurate diagnosis and more effective treatments. The main goals of the PTSD Research Program are:  Improving the diagnosis and treatment of PTSD  Improving our understanding of the unique stressors faced by law enforcement professionals and members of the armed forces  Identifying both positive and negative ways that PTSD sufferers deal with stress  Developing effective tools and treatments to assist sufferers in the management of stress in order to maximize emotional and physical health  Developing novel interventions to prevent PTSD

THE MULTIPLE TRAUMAS OF YOUTH BEHIND BARS Lecturer: Terry Kupers, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to understand: 1) the prevalence of trauma among the juvenile population in the criminal justice system; 2) the additional traumatic effects and lasting disability caused by harsh conditions of confinement; and 3) the vulnerabilities of youth in adult correctional facilities. SUMMARY: Youth in the criminal justice system usually suffered multiple traumas prior to arrest. Many are survivors of childhood physical and sexual abuse and witnessed or were the object of violence in the home and in the community. There were failures in school and, very often, substance abuse. For those with known mental illness, public mental health services were less than ideal. After being arrested they spend time in jail, a youth facility, or prison (for example, if they are tried as an adult). Huge inequities vis a vis class and race mean that youth of color from the lowest socioeconomic strata are most likely to be incarcerated. In correctional settings a large proportion are the victims of violence or sexual abuse. Too often the inappropriate behaviors they exhibit while confined are interpreted by authorities as willful disobedience rather than symptoms of their multipli-traumatized psychiatric condition. They very often find their way into segregation or isolative confinement. There, forced idleness and isolation exacerbate their emotional problems, but to the extent their symptoms include acting out and rule-breaking, they are punished with ever longer stints in segregation. In many states they are actually placed in isolative confinement "for their own protection." In the significant proportion of these youth who are predisposed to serious mental illness, the isolation causes further emotional damage. Assaults, harsh prison conditions and isolative confinement exacerbate or trigger psychiatric decompensations and suicide crises. The rate of completed suicides is unacceptably high. Essentially a vicious cycle of symptomatic behaviors, inappropriately harsh punishments and re-traumatization evolves into a downward spiral. Meanwhile, along with isolation there is discontinuation of the educational and rehabilitative programs they would need to become functional. Their eventual prognosis, and their chances of remaining "clean and sober" and succeeding at "going straight" in the community after release, are greatly reduced.

LATEST DEVELOPMENTS IN THE ASSESSMENT AND TREATMENT OF DISABILITY IN SEVERE MENTAL ILLNESS Lecture Chair: Philip Harvey, Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to understand: 1) the measurement and treatment of cognitive and functional deficits in schizophrenia; 2) what types of outcome measures are best suited to detect changes in cognition and functioning; and 3) what types of concurrent interventions are most likely to lead to real world functional gains. SUMMARY: Impairments in cognitive functioning and functional capacity are among the major contributors to the poor functional outcomes experienced by many people with schizophrenia. In the recent past, there have been a number of cognitive remediation strategies developed to improve cognition and reduce disability in schizophrenia, with some of these interventions having substantially greater benefits than older efforts. This lecture will review the state of the art of the measurement and treatment of cognitive and functional deficits in schizophrenia. On the assessment side, it is important to consider what types of outcome measures are best suited to detect changes in cognition and functioning. Although there are endorsed measures for pharmacological interventions, would these same measures be best for use in detection of remediation-induced change? On the treatment side, there are several different questions to address. These include identifying the treatment strategies that work the best, at what level their benefits occur (cognitive perform-

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NOV 02, 2014

SUMMARY: Psychiatrists are often asked if the behavioral addictions, such as shopping, food, sex, love, texting, e-mailing and gambling, are really bona fide medical disorders or just an exaggeration of everyday social and personal ailments. While there is little doubt that these conditions present with unique and poorly researched challenges in everyday clinical practice, the overarching hallmark of addiction-the loss of control over one's own life-seems to be quite similar for both substances and behaviors that hijack a person's pleasure and reward brain circuitry. Typically, psychiatrists and other health providers rely on their experience treating substance use disorders in order to address these emerging conditions. There is little doubt that extreme forms of these impulsivecompulsive behaviors share a number of characteristics with the severe forms of substance use disorders. four major symptoms can be readily recognized in most addictions, whether they are substance-driven, like cocaine and tobacco, or simply behaviorally-driven, like gambling and shopping: 1. Tolerance-the need to use the substance or perform the troublesome behavior at higher doses, or more and more frequently, in order to achieve the same effect. 2. Withdrawal-the uncomfortable feeling (and sometimes devastating syndrome), following abrupt discontinuation of the substance or the behavior. 3. An obsession that seems to "eat up" the person from within-having little interest in anything other than the addictive agent, constantly coming back to "how am I going to use," "how am I going to pay for it," "how am I going to come down," and "how am I going to start the process all over again." 4. External consequences of the addiction in terms of the person's finances, health, interpersonal relationships, or legal affairs. Apart from these relatively common symptoms, some addictions have additional, unique characteristics, as in the case of the problematic gambler who often exhibits frantic efforts to recoup losses. On the other hand, moderate forms of compulsivity present us with a dilemma. Most clinicians agree that surfing the Internet for 2 hours a day is probably OK, but 16 hours a day is not. But how about 4 or 8 hours a day? Where does one draw the line if the person has not completely lost control of her or his life but is still struggling? And then there are behaviors that have significant impulsive or compulsive traits but for which we have not quite made up our minds whether we should classify them as addictions or not. Are there such things as work, exercise, food, relationship, or love addictions? When it comes to the behavioral addictions, we have a lot more work to do in order to arrive at reliable diagnostic criteria, build useful assessment tools, and develop effective psychosocial and pharmacological treatments.

BIPOLAR DISORDER IN PRIMARY CARE: CLINICAL CHARACTERISTICS AND GAPS IN QUALITY OF CARE Lecturer: Joseph M. Cerimele, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) recognize the importance of identifying bipolar disorder in primary care patients; 2) describe the clinical characteristics of patients with bipolar disorder seen in primary care settings; and 3) discuss research directions for improving quality of care of patients with bipolar disorder seen in primary care. SUMMARY: Most patients with psychiatric illnesses present initially to primary care settings. Over the past 20 years collaborative care has been developed to treat populations of primary care patients with depression and anxiety disorders, and a substantial evidence base supports the use of collaborative care in primary care. Real-life use of collaborative care in large health systems has revealed that approximately 10-15% of primary care patients referred for collaborative care actually have bipolar disorder. A smaller evidence base exists for how to best treat patients with bipolar disorder in primary care. Patients with bipolar disorder present to primary care for several reasons, including care of medical problems which occur often in patients with bipolar illness, care of depressive symptoms, or with symptoms related to anxiety or substance use which are common in patients with bipolar disorder. This presentation will focus on understanding the presentation of bipolar disorder in primary care and describing the clinical characteristics of a large sample of primary care patients with bipolar disorder encountered in a statewide collaborative care system in Washington State. The presentation will also include a discussion with the audience regarding future directions on research related to improving the quality of care delivered to primary care patients with bipolar disorder.

THE BEHAVIORAL ADDICTIONS: GAMBLING AND SEX AND SHOPPING AND SURFING AND TEXTING, OH MY! Lecturer: Petros Levounis, M.D., M.A. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) describe the impulsivity- compulsivity spectrum of illness; 2) contrast the psychiatric and social manifesttations of the behavioral addictions with substance use disorders; and 3) identify promising serotonergic with dopaminergic psychopharmacological approaches to treatment.

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2014 INSTITUTE ON PSYCHIATRIC SERVICES

Symposia OCT 30, 2014

NO. 2 - PHARMACY DASHBOARD TO ENHANCE EVIDENCE-BASED PRACTICES Presenter: Daina Wells, Pharm.D. SUMMARY: Easy access to up-to-date information on a provider’s patients is vital to continuous improvement in clinical practice. To address this need, we developed provider-level mental health dashboards for specific clinical areas, e.g., metabolic monitoring, polypharmacy. This information is focused on key messages for use by both administrators and clinical team members within the Veterans Administration. These audit and feedback tools leverage regional and national data to produce a clinical performance dashboard that generates current, visually-intuitive reports at the regional, local facility, and individual patient level. Data collection for the dashboards includes 100% sampling of robust and complex data sets that are updated daily. These innovative tools provide a snapshot global view of patient panels and allow providers to assess actionable patient-level information in order to change individual care and align with evidence-based practice.

ENHANCING PSYCHIATRIC CARE WITH INFORMATICS Chair: Steven E. Lindley, M.D., Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) name three ways measurement-based care using an electronic medical record improves psychiatric care; 2)describe two smart phone applications that can be used to improved outpatient mental health treatment outcomes; 3) identify three advantages to patient entered data into an electronic medical record in improving outcomes in patients with schizophrenia; and 4)name three areas of evidencedbased psychiatric care that can be improved through providing dashboards to providers. SUMMARY: An increasing array of computer and mobile device- based tools are available to mental health patients and providers. How to best adapt these new informatics tools into current psychiatry practice in a manner that enhances both patient care and clinical efficiency presents a challenge. In this symposium, the development and implementation of four different informatics tools within the Veterans Administration (VA) Health Care System will be described; 1) mobile applications designed for psychoeducation and self-help for those suffering from PTSD and other mental health problems, 2)web-based mental health dashboards designed to enhance evidence-based psychopharmacology and psychotherapy, 3) innovative patient-facing kiosks used to support implementation of timely, evidence- based services and improve weight, employment, treatment, and outcomes, and 4) a provider-driven software tool designed to enhance measurement- based care within the VA. We will discuss the lessons learned in the development and implementation of these tools and how the information gained can inform the disseminated of similar tools into a variety of mental health treatment settings.

NO. 3 - PROVIDER-DRIVEN DEVELOPMENT OF MEASUREMENT-BASED CARE SOFTWARE Presenter: Steven E. Lindley, M.D., Ph.D. SUMMARY: Systematically collecting and recording assessment, treatment, and side effect data and using this data to inform treatment decisions—measurement-based care—is essential to excellent mental health care. Measurement-based care improves overall quality of care and enhances efficacy and implementation research efforts. But it is difficult to achieve without the right tools to assist providers. Tools can be time consuming to use, impede workflow, and don’t collect clinically useful data. We developed software that is integrated into a large electronic medical record system and into the provider’s workflow. The software provides a single, integrated system for documenting, recording and analyzing a) clinical data, b) interventions, and c) assessments. It is being developed with on-going input from outpatient mental health clinicians. The overall goal is to drive the development of mental health information technology tools that have maximum impact on the quality of patient care.

NO. 1 - MOBILE HEALTH APPLICATIONS: IMPLICATIONS FOR THE FUTURE OF PTSD SERVICES DELIVERY Presenter: Josef I. Ruzek, Ph.D. SUMMARY: Mobile applications that provide education and enable selfmanagement of PTSD symptoms are rapidly being developed and tested. More than a gimmick, these technologies hold promise for addressing key challenges in the delivery of effective treatments. Using as illustrations a range of smartphone apps developed by the National Center for PTSD, we argue for the capacity of mobile health technologies to improve evidence-based decision- making, foster outcomes monitoring, enable clinicians to see more patients and address a wider range of problems, reduce training needs, empower paraprofessional care, and engage patients and families in recovery following traumatization.

NO. 4 - USING PATIENT-FACING KIOSKS TO SUPPORT IMPROVED CARE AT MENTAL HEALTH CLINICS Presenter: Alexander S. Young, M.D., M.P.H. SUMMARY: Evidence-based services improve outcomes in schizophrenia, but many patients do not receive such services. This gap has been perpetuated by a lack of routinely collected data on patients' clinical status and the treatments received. However, routine data collection can be completed by patients themselves, when aided by information technology. In a controlled trial, eight medical centers of the VA were assigned to implementation or usual care for 571 patients with schizophrenia who were overweight. Implementation was informed by data from patient-facing kiosks, and included clinical champions, education, social marketing, and evidence-based quality improvement teams. Implementation resulted in patients being more likely to use weight 21

AMERICAN PSYCHIATRIC ASSOCIATION

services, getting services 5 weeks sooner, and using 3 times more visits. Mental health has been slow to adopt information technology. This is among the first studies to evaluate implementation of automated data collection at these clinics. _______________________________________________________

and mortality due to OUD is a public health imperative, and evidence-based medication therapies for OUD have been demonstrated across studies and regional cohorts to consistently double the rates of opioid abstinence achieved in treatment for OUD, while medical detoxification alone results in rapid relapse (> 80% in most studies).

ADVANCES IN ADDICTION PHARMACOTHERAPY

NO. 2 - ALCOHOL PHARMACOTHERAPY: WHAT IS THE FIRST LINE MEDICATION? Presenter: Steven Batki, M.D. SUMMARY: During the past 20 years, major advances have been made in understanding the neurobiology of alcohol use disorder (AUD). This increased understanding has led to discovery of effective medications, several of which have received FDA approval for relapse prevention. This presentation will summarize the state of the art regarding the optimal use of the FDA- approved medications - naltrexone, acamprosate and disulfiram. The presentation will cover some key clinical variables affecting treatment response such as early vs. late onset of AUD, and abstinence versus continued alcohol use at the start of treatment. The presentation will also discuss the use of newer medications that show promise, such as topiramate, baclofen, and ondansetron. New findings in the pharmacotherapy of AUD in the presence of co-occurring psychiatric disorders will also be covered.

Chair: Larissa Mooney, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to identify: 1) agonist, partial agonist, and antagonist medications for the treatment of opioid disorders; 2) FDA approved and emerging pharmacotherapies for the treatment of alcohol use disorders; and 3) FDA approved medications for the treatment of nicotine dependence. SUMMARY: Substance use disorders remain a significant public health concern, with 10% and 30% of U.S. adults meeting lifetime criteria for drug and alcohol use disorders, respectively. The addicted patient presents numerous dilemmas to the treating psychiatrist, not least of which is the proper selection of the safest and most efficacious pharmacologic treatments for substance use disorders and for some of the co-occurring psychiatric disorders that accompany substance use. This symposium will address emerging and evidence-based pharmacologic treatment options for the addicted patient, focusing on four common substance use disorders: opioids, alcohol, stimulants, and nicotine. Attendees will gain a basic knowledge of state-of-the-art approaches to managing these disorders and the evidence-base for FDA approved and offlabel pharmacotherapy choices in these four clinical domains. While there are FDA approved medication options for the treatment of opioid, alcohol and nicotine use disorders, there are no approved medications for cocaine and methamphetamine dependence despite decades of research. As a result, evidence-based behavioral treatments are considered the first-line approach to reduce stimulant use and facilitate abstinence. The prescription of opiate agonist/partial agonists and antagonists hinges on balancing benefits with potential harms and requires examination of the limited data on direct comparison of the efficacy of the different medications. Similarly, the evolving list of medications available for alcohol use disorder and nicotine cessation require that the clinician have a firm grasp of the risks, benefits, and latest data from clinical trials. Evidence from research studies suggests that certain medications may be useful in restoring neurotransmitter deficits caused by stimulant use and target symptoms associated with withdrawal, with the goal of initiating abstinence or reducing relapse. This symposium will review the latest evidence to guide clinical decision-making when selecting pharmacotherapy for addicted and dually diagnosed patients.

NO. 3 - MEDICATIONS UNDER DEVELOPMENT FOR STIMULANT USE DISORDERS Presenter: Larissa Mooney, M.D. SUMMARY: The use of stimulants including methamphetamine (MA) and cocaine is associated with a broad range of psychiatric symptoms, medical consequences, and other public health impacts. Despite decades of research, no medications have yet been FDA approved for the treatment of cocaine or MA use disorder; evidence-based behavioral treatments are considered the first-line approach to reduce stimulant use and facilitate abstinence. Evidence from research studies suggests that some medications may be useful in restoring neurotransmitter deficits caused by stimulant use and target symptoms associated with withdrawal, with the goal of initiating abstinence or reducing relapse. NO. 4 - PHARMACOTHERAPY FOR NICOTINE DEPENDENCE Presenter: Petros Levounis, M.A., M.D. SUMMARY: The most recent evidence of safe and effective pharmacological interventions for people who suffer from tobacco use disorders will be reviewed. We will present best practices for the use of food and drug administration (fda) approved medications: bupropion, varenicline, and nicotine replacement therapies (patch, gum, inhaler, lozenges, and nasal spray). Contraindications and major advantages and disadvantages for each intervention will be discussed, as well as strategies for combining pharmacological interventions, when appropriate, for maximum efficacy. The controversy over the reported neuropsychiatric sequelae of varenicline and bupropion, the black box warnings, and the scientific evidence supporting or refuting these claims will be critically assessed. While research in the pharmacotherapy of tobacco use disorders appears to have slowed down in recent years, we will briefly review a few key experimental pharmacological agents, including the nicotine vaccine.

NO. 1 - MEDICATIONS FOR OPIOID USE DISORDERS: PRACTICAL CONSIDERATIONS IN SELECTING OPIOID AGONIST AND ANTAGONIST THERAPIES Presenter: John A. Renner Jr., M.D. SUMMARY: The prevalence of opioid use disorders (OUD) has increased 10-fold over the past decade and both heroin use and illicit prescription opioid analgesic use has increased dramatically among youth cohorts, leading to a national epidemic of opioid-related overdose deaths. The prevention of morbidity 22

2014 INSTITUTE ON PSYCHIATRIC SERVICES

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NO. 2 - INTRODUCTION TO SOCIAL DETERMINANTS OF MENTAL HEALTH Presenter: Ruth S. Shim, M.D., M.P.H. SUMMARY: This presentation will elucidate the concept of social deteminants of mental health and mental illness using WHO’s definition of social determinants of health as a framework. It will discuss the “syndemic” concept and population health, gene-environment interactions and the ability to influence the social determinants through policy change. It will review the literature on health inequalities and health inequities along socioeconomic gradients across countries and within countries. Emphasizing the connection to social justice, this presentation will also discuss how addressing the social determinants of mental health is a moral imperative.

WHEN THE COMMUNITY IS YOUR PATIENT: POLICY PRESCRIPTIONS FOR THE SOCIAL DETERMINANTS OF MENTAL HEALTH. PART I: SOCIAL AND INTERPERSONAL DETERMINANTS Chairs: Michael T. Compton, M.D., M.P.H., Ruth S. Shim, M.D., M.P.H. Discussant: David A. Pollack, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the concept of the social determinants of mental health; 2) list three social determinants that can be characterized as "social" or "interpersonal" determinants of mental health; and 3) discuss three activities that community psychiatrists may engage in to improve mental health in their communities by addressing social determinants. SUMMARY: This presentation challenges psychiatrists to consider their responsibility in addressing policies that are damaging to the mental health of our communities. We will focus on the social determinants of mental health and mental illnesses, which are defined as those factors stemming from where we are born, grow, live, work, learn, and age that contribute to or detract from the mental health and well-being of individuals and communities. Although mental illnesses are often underpinned by genetic predisposition and gene-byenvironment interactions, we will highlight the social determinants of such disorders, which are likely modifiable through social and policy interventions. The World Health Organization estimates that there are more than 10 major social determinants that affect health; this symposium will serve to introduce mental health providers to several of these determinants in greater depth, emphasizing the impact on mental health and illness. After a series of presentations, former U.S. Surgeon General Dr. David Satcher will discuss "a policy prescription" for the various social determinants presented. This is Part I of a two-part Symposium on the social determinants of mental health. Part I focuses on those social determinants of mental health that can be thought of as social and interpersonal in nature, whereas Part II pertains to those social determinants of mental health that can be characterized as "environmental."

NO. 3 - POVERTY/INCOME INEQUALITY AS SOCIAL DETERMINANTS Presenter: Marc W. Manseau, M.D., M.P.H. SUMMARY: Economic factors, including both deprivation and inequality, are important determinants of mental health and mental illness. This presentation will highlight and address individual and area-level poverty, and the impact of the widening gap between rich and poor in the US. Mediators and moderators of the association between income inequality and poor mental health will be presented. Possible policy solutions will be discussed. NO. 4 - SOCIAL ISOLATION AND EXCLUSION AS SOCIAL DETERMINANTS Presenter: Kenneth S. Thompson, M.D. SUMMARY: Social support and healthy social networks are known to be good for one's physical and mental health. On the other hand, social isolation and social exclusion are associated with poor physical and mental health outcomes. This presentation will review the literature on social isolation and social exclusion as social determinants of mental health, and will present potential solutions that can be effected at the clinical and policy level. NO. 5 - DISCRIMINATION/DEMOGRAPHIC INEQUALITY AS A SOCIAL DETERMINANT Presenter: Camara P. Jones, M.D., M.P.H., Ph.D. SUMMARY: Inequalities and discrimination that arise from society based on the innate characteristics of a group (e.g., based on race, ethnicity, or sexual orientation) are detrimental to both physical and mental health. Furthermore, many of the social determinants of health are in part driven by discrimination and inequalities based on demographics. This presentation will review the literature pertaining to discrimination and demographic inequalities as a social determinant of mental health, and present solutions that must be enacted at the policy level. _______________________________________________________

NO. 1 - ADVERSE EARLY LIFE EXPERIENCES AS SOCIAL DETERMINANTS Presenter: Carol Koplan, M.D. SUMMARY: This presentation will review of the impact of early childhood experiences upon mental health, highlighting the “Adverse Childhood Experience” (ACE) study, childhood trauma, foster care and separation from parents, and consequences of perinatal depression and bullying. Recommended interventions will focus on early home visits, prevention of child abuse, prevention and treatment of perinatal depression, importance of the two- generation approach, and increasing social inclusion and connectedness.

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of distress and mental illness and share strategies for connecting ministries of churches, mosques, or synagogues to public mental health systems of care for chronically mentally ill patients.

AT THE INTERSECTION OF SPIRITUALITY AND MENTAL HEALTH: PSYCHIATRISTS AND FAITH LEADERS WORKING TOGETHER Chair: Altha Stewart, M.D.

NO. 3 - MENTAL ILLNESS AND FAMILIES OF FAITH: HOW CONGREGATIONS CAN RESPOND Presenter: Susan Gregg-Schroeder SUMMARY: The presenter will describe her work in founding Mental Health Ministries, an interfaith web-based ministry that provides educational resources to help erase the stigma of mental illness in faith communities. The presentation will include how to help faith communities become caring congregations for both people living with a mental illness and those who love and care for them based on the “caring congregations” five step model. The steps are: Education, Commitment, Welcome, Support, and Advocacy. She will also share her personal journey to recovery to illustrate the model in action.

EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) recognize ways for faith and psychiatric leaders to work together more effectively to address the emotional health needs of general public, including ministers; 2) identify opportunities for establishing local collaboratives with clergy in their home community; and 3) educate psychiatrists about the important role of spirituality during the recovery process for many people with behavioral health conditions. SUMMARY: The APA, APF and Interfaith Disability Advocacy Coalition (IDAC) convened a meeting in July 2014 of over 40 diverse faith, psychiatric and other MH leaders to establish the MH and Faith Community Partnership. Its aim is to create a collaborative relationship between psychiatrists and faith leaders to foster a dialogue between the two fields, reduce stigma, and address the medical and spiritual dimensions of people seeking care for their emotional health needs. The partnership will create new resources to provide training to spiritual leaders about mental health and substance abuse issues, and for psychiatrists about faith and the role of faith communities in behavioral health recovery. This symposium will include presentations by leaders in both the faith and psychiatric community who are currently working on establishing the collaborative relationships needed to impact the "health of the whole person" as described by partnership member and mental health advocate, former Congressman Patrick Kennedy. Speakers will address efforts to begin the dialogue with our faith colleagues to whom many turn in times of emotional distress, reduce stigma, and share ways to educate each group on the role of the other in behavioral health recovery. There will be ample time for Q&A and interaction with participants.

NO. 4 – SPIRITUALLY-INTEGRATED TREATMENT Presenter: John Peteet, M.D. SUMMARY: The presenter will describe his work at the interface between spirituality/religion and psychiatry in clinical practice. He will review his work on the DSM-5 research agenda related to spiritual and religious issues in psychiatric diagnosis. He will also provide updates on the work of the American Psychiatric Association’s Caucus on Religion, Spirituality and Psychiatry. NO. 5 - FAITH, SPIRITUALITY AND MENTAL HEALTH RECOVERY Presenter: Alan Johnson SUMMARY: The presenter is co-founder of the interfaith network on mental illness (www.inmi.us) and national chair of the United Church of Christ Mental Health Network (www.mhjn-ucc.blogspot.com). A retired chaplain at the Children’s Hospital in Denver, his presentation will address the understanding of faith and spirituality as potential resources in one’s recovery in mental health and describe his work in providing mental health educational programs targeted at faith communities and developing the introduction to spirituality for the mental health first aid program. Finally, he will share his personal story, as a father of a son who lives with a mental illness and a brother of one who ended his life, from the perspective of an ordained clergy.

NO. 1 - THE MENTAL HEALTH AND FAITH COMMUNITY PARTNERSHIP: PSYCHIATRISTS AND FAITH LEADERS WORKING TOGETHER Presenter: Meenatchi Ramani, M.D. SUMMARY: The presenter will briefly describe the goals and initial work of the newly formed APA initiative, the Mental Health and Faith Community Partnership Steering Committee. Beginning with a dialogue on opportunities for mutual understanding and action among members of the faith and psychiatric communities, APA/APF leadership met with partners at AAPD/IDAC. She will discuss the short term projects identified and the resources needed for those projects that will highlight the intersection of Mental Health and Faith. NO. 2 - COMBATTING THE STIGMA OF MENTAL ILLNESS IN THE FAITH COMMUNITY Presenter: James Griffith, M.D. SUMMARY: The presenter has worked extensively in the area of spirituality and mental health and will discuss opportunities for engaging religious professional or groups to address the stigma against psychiatry, psychiatric patients and mental illness. He will also help describe how to assist religious professionals in distinguishing between normal syndromes

NO. 6 - COLLABORATING WITH FAITH COMMUNITY LEADERS TO HELP PHYSICIANS WITH SPIRITUAL STRUGGLES Presenter: James Lomax, M.D. SUMMARY: The presenter will discuss his work at the interface between religion, spirituality, and healing from a psychiatric and psychoanalytic perspective. He will describe his work at the interface between spirituality/religion and psychiatry in clinical practice and the work of the Institute for Spirituality and Health. He will review his current work in the area of helping physicians with spiritual struggles and will include a discussion of a case that illustrates some of the issues he will address. _______________________________________________________

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2014 INSTITUTE ON PSYCHIATRIC SERVICES

educate ourselves, inform ourselves, and use our positions to help all underserved and disadvantaged groups get the best care possible. In this symposium, we tackle one important group, the LGBT community. By bringing more awareness and evidence-based practice to the source of care, it is our hope that LGBT patients will ultimately have better psychiatric outcomes and better health overall.

OCT 31, 2014

MISTAKEN IDENTITY: IMPROVING CARE FOR LESBIAN, GAY, BISEXUAL AND TRANSGENDER (LGBT) PATIENTS FROM EDUCATION TO IMPLEMENTATION Chair: Amir Ahuja, M.D.

NO. 1 - TEACHING ABOUT CLINICAL ISSUES IN RELATION TO SEXUAL ORIENTATION IN THE ERA OF DSM-5 Presenter: Robert P. Cabaj, M.D. SUMMARY: Homosexuality was removed from the DSM in 1973 and Ego Dystonic Homosexuality was removed in 1986 and there are no categories in DSM-5 touching sexual orientation, so why is there a need to keep teaching about clinical issues and sexual orientation? Though there is no psychopathology in any variation of sexual orientation, people with minority sexual orientations do face clinical challenges that can be related to the acceptance—or not—of that sexual orientation either by society or by that individual. How to teach but not imply psychopathology is an important way to help behavioral health and primary care providers be better equipped to provide optimal clinical care to people with minority sexual orientations. Both content and ways of teaching will be discussed.

EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) articulate the way in which to approach the issue of LGBT mental health and inform others on this topic in a non-judgmental, culturally-sensitive way; 2)identify and enumerate the connections between discrimination and minority stress and future (or concurrent) psychiatric morbidity and mortality; 3) identify the unique concerns of the LGBT population in regards to patterns of substance use, unique epidemiological patterns and what works best in treating this population; 4) synthesize the presentations to develop a broader knowledge about origins of mental illness in LGBT people, clinical concerns unique to this population, and best clinical and educational practices; and 5) formulate strategies to improve the mental health, physical health, and care delivery in regards to LGBT people, and maximize cultural competency within the psychiatric profession. SUMMARY: It has been repeatedly shown throughout the academic literature that there are clear health disparities for the Lesbian, Gay, Bisexual, and Transgender (LGBT) population. Mental healthcare, and particularly psychiatry, is no different. One can see this in the way that the issue of LGBT mental health is discussed. There are often major gaps in knowledge for even the most well-meaning psychiatrists. Often, this issue is discussed with inherent biases that we cannot correct until they are brought to light. Frequently there is a stress on psychopathology as opposed to mental wellness, which frames the LGBT population as significant only for lack of health. Much work can be done on improving the way this topic is approached, taught, and conveyed in academic settings. Another way we can see it in the way that care is informed and researched. Too often there is an assumption of illness inherent to a certain population without much thought as to its origins. In a heterosexualdominant society, one can ignore the ways in which minority stress can influence the physical and mental health of the LGBT minority. More frequent exposure to abuse, bullying, domestic violence, and discrimination on all levels takes its toll on the health of this population. The way this is understood can better inform compassionate care, and can lead to more attention and intervention at a social level to improve patient outcomes. A final way that these health care disparities are seen is in the delivery of care. In particular, substance abuse care is frequently laden with judgment. This is true for heterosexual patients, but even more so for the LGBT minority. By understanding the roots of the substance use patterns and behaviors of LGBT people, one can become more adept at dealing with some unique concerns these patients have. One can also be more efficient and have better outcomes by fostering a sense of understanding and inclusiveness in care. This can only happen by being culturally competent and keeping up with trends in LGBT culture. Why is this important? A significant portion of our populace, and therefore of our patients, is needlessly suffering due to a lack of being understood and properly cared for. As psychiatrists, we have a responsibility to

NO. 2 - BIOLOGICAL EMBEDDING OF TOXIC STRESS AND HEALTH DISPARITIES IN LGBT INDIVIDUALS Presenter: Andres F. Sciolla, M.D. SUMMARY: Several medical and psychiatric health disparities have been documented in LGBT populations. A robust predictor of health disparities is the presence of childhood adversities, ranging from interpersonal abuse and neglect to violence exposure and structural disadvantage, such as low SES and discrimination. Research has documented the staggering risk of LGBT individuals of exposure to early life adversities, such as childhood sexual abuse. Insufficient attention has been paid to the clinical, research and policy implications of the contribution of adverse childhood experiences to health disparities in LGBT individuals. This presentation seeks to address these knowledge and practice gaps by offering a critical overview of the extant literature as well as hands-on, practical suggestions for healthcare providers of LGBT individuals. These suggestions will focus on the clinical care of LGBT ethnic minorities affected by various syndemics, and signal a paradigm shift for future practice. NO. 3 - STIMULANT USE AMONG GAY MEN OVER THE PAST 40 YEARS: FROM COCAINE TO ECSTASY, TINA, "BATH SALTS," AND SMILES Presenter: Petros Levounis, M.A., M.D. SUMMARY: The rise in stimulant use among gay and bisexual men in urban centers over the past 20 years has resulted in a greater understanding of the biological, psychological, and cultural dimensions of the problem, as well as the development of specific treatments for this population of patients. We will review (a) the crack cocaine epidemic of the 1980s, which seems to had affected equally gay and straight populations; (b) the methylene-dioxy- methamphetamine rage of the 1990s; (c) the explosion of crystal methamphetamine in the gay male circuit party scene of the 2000s; and finally (d) the new phenomenon of the synthetic cathinones (‘bath salts”) 25

AMERICAN PSYCHIATRIC ASSOCIATION

and related substances. Culturally informed individual and group psychotherapy, based on the principles of Motivational Interviewing and frequently organized around the MATRIX Model (a multi-faceted cognitive-behavioral modality that includes contingency management and addresses frequently co-occurring hypersexuality), appears to be most effective. _______________________________________________________

NO. 2 - UNEMPLOYMENT AND UNDER-EMPLOYMENT AS SOCIAL DETERMINANTS Presenter: Brian McGregor SUMMARY: Unemployment and under-employment are known to be associated with poorer physical health and poorer mental health. This is partly due to their effects on poverty/income inequality, poor housing, food insecurity, poor access to care, and other social determinants of health. This presentation will review the literature on unemployment and under-employment as social determinants of mental health, and will address how policy solutions could improve the mental health of individuals and communities, and reduce the risk of mental illnesses.

WHEN THE COMMUNITY IS YOUR PATIENT: POLICY PRESCRIPTIONS FOR THE SOCIAL DETERMINANTS OF MENTAL HEALTH. PART II: ENVIRONMENTAL DETERMINANTS Chairs: Michael T. Compton, M.D., M.P.H., Ruth S. Shim, M.D., M.P.H. Discussant: Altha Stewart, M.D.

NO. 3 - A BRIEF INTRODUCTION TO THE SOCIAL DETERMINANTS OF MENTAL HEALTH Presenter: Michael T. Compton, M.D., M.P.H. SUMMARY: This presentation will define key concepts such as social determinants of health, health inequalities and inequities, health disparities, and social justice. Ways of conceptualizing the social determinants of mental health will be reviewed, setting the stage for subsequent presentations in this symposium.

EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the concept of the social determinants of mental health; 2) list three social determinants that can be characterized as "environmental" social determinants of mental health; and 3) describe three ways that psychiatrists can be involved in addressing environmental social determinants of health that affect the overall mental health of a community or population. SUMMARY: This presentation challenges psychiatrists to consider their responsibility in addressing policies that are damaging to the mental health of our communities. This is Part II of a twopart Symposium on the social determinants of mental health, which are defined as those factors stemming from where we are born, grow, live, work, learn, and age that contribute to or detract from the mental health and wellbeing of individuals and communities. Although mental illnesses are often underpinned by genetic predisposition and gene-by- environment interactions, we will highlight the social determinants of such disorders, which are likely modifiable through social and policy interventions. The World Health Organization estimates that there are more than 10 major social determinants that affect health; this symposium will continue to introduce mental health providers to several of these determinants in greater depth, emphasizing the impact on mental health and illness. This section pertains to those social determinants of mental health that can be characterized as "environmental" determinants. After a series of presentations, former American Psychiatric Foundation President Dr. Altha Stewart will discuss "a policy prescription" for the various social determinants presented.

NO. 4 - LOW EDUCATION AND EDUCATIONAL INEQUALITIES AS SOCIAL DETERMINANTS Presenter: Rebecca A. Powers, M.D., M.P.H. SUMMARY: Poor education, low educational attainment, and educational inequalities lead to poorer occupational achievement, lower income, and other social determinants of health. The presenter will review the evidence on education-related social determinants of mental health. Potential policy-level solutions will be described. NO. 5 - HOUSING INSTABILITY AND ADVERSE FEATURES OF THE BUILT ENVIRONMENT AS SOCIAL DETERMINANTS Presenter: Lynn Todman, Ph.D. SUMMARY: The places where we live, play, work, and age have an impact on both physical and mental health. This presentation will review the literature on how housing and "the built environment" impact the mental health of individuals and communities. The importance of health impact asessments of policies will be presented. Policy changes that would enhance housing and improve the built environment—and thus improve mental health and reduce the risk of mental illnesses—will be presented. _______________________________________________________

NO. 1 - POOR ACCESS TO CARE AS A SOCIAL DETERMINANT Presenter: Frederick J. P. Langheim, M.D., Ph.D. SUMMARY: This presentation will focus on the effects of poor access to care, specifically addressing unequal distribution and access to healthcare, varying quality of healthcare, and inequality of the mental health care system compared to the general healthcare system. The potential preventive benefits of mental health integration into primary-care-based, publicly funded, universal health care will be discussed.

HIV PSYCHIATRY TODAY Chair: Lawrence M. McGlynn, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) learn approaches to diagnosis and treatment of HIV-Associated Neurocognitive Impairment/Disorder; 2) understand the impact of substance use and coinfection with hepatitis C on HIV care; and 3) recognize common drug interactions between HIV medications and psychotropic medications. 26

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SUMMARY: To successfully diagnose and treat patients with HIV/AIDS, psychiatrists need to understand the complex biomedical aspects of AIDS as well as patterns of HIV infection in special patient populations. Good clinical care can frequently be impeded by the presence of subtle cognitive impairments, substance use disorders, or coinfection with Hepatitis C. New medications with new side effect profiles make treating HIV-infected persons with a psychiatric illness increasingly complex. This session will provide the most up-to-date information on diagnosis and treatment of cognitive disorders, the impact of prescription drug and methamphetamine use on care, new treatments for hepatitis c and syphilis, and the safest psychotropics to use with some of the new HIV medications. The session will include a lecture followed by an interactive question and answer period providing participants the opportunity to discuss individual clinical concerns.

NO. 3 - PRACTICAL HIV PSYCHOPHARMACOLOGY: INDICATIONS, SIDE EFFECTS, AND INTERACTIONS Presenter: Wilson Ly, Pharm.D. SUMMARY: To successfully diagnose and treat patients with HIV/AIDS, psychiatrists need to understand the complex biomedical aspects of AIDS as well as patterns of HIV infection in special patient populations. Good clinical care can frequently be impeded by the presence of subtle cognitive impairments, substance use disorders, or coinfection with Hepatitis C. New medications with new side effect profiles make treating HIV-infected persons with a psychiatric illness increasingly complex. This session will provide the most up-to-date information on diagnosis and treatment of cognitive disorders, the impact of prescription drug and methamphetamine use on care, new treatments for hepatitis c and syphilis, and the safest psychotropics to use with some of the new HIV medications. The session will include a lecture followed by an interactive question and answer period providing participants the opportunity to discuss individual clinical concerns. _______________________________________________________

NO. 1 - HIV-ASSOCIATED NEUROCOGNITIVE IMPAIRMENT: ASSESSMENT AND SCREENING Presenter: Karl Goodkin, M.D., Ph.D. SUMMARY: To successfully diagnose and treat patients with HIV/AIDS, psychiatrists need to understand the complex biomedical aspects of AIDS as well as patterns of HIV infection in special patient populations. Good clinical care can frequently be impeded by the presence of subtle cognitive impairments, substance use disorders, or coinfection with Hepatitis C. New medications with new side effect profiles make treating HIV-infected persons with a psychiatric illness increasingly complex. This session will provide the most up-to-date information on diagnosis and treatment of cognitive disorders, the impact of prescription drug and methamphetamine use on care, new treatments for hepatitis c and syphilis, and the safest psychotropics to use with some of the new HIV medications. The session will include a lecture followed by an interactive question and answer period providing participants the opportunity to discuss individual clinical concerns.

INTEGRATING CARE: PSYCHIATRY AND MEDICINE IN SERVICE TO OUR PATIENTS Chair: Paul Summergrad, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identity evidence based models of integrated care and the core principles associated with these models; 2) understand the role of the psychiatrists in emerging models of care in a reformed health care system; and 3) recognize the major causes of medical comorbidity in patients with serious mental illnesses and the psychiatrists' role in improving the health status of this group who have a shortened life expectancy. SUMMARY: The integration of primary health and behavioral health has a robust evidence base and the dissemination and adoption of this practice has progressed rapidly. The idea that bringing together the diverse cultures of primary care and behavioral health to better treat mental illnesses in primary care and improve the health status of those with mental illnesses in public mental health settings both intrigues and excites professionals in both disciplines. In primary care settings the development and implementation of the IMPACT and TEAMCare models have proven that collaborative care models, which introduce new members to the health care team: a consultant psychiatrist and a care manager, can improve outcomes in the treatment of mental illness, are cost effective to implement and can reduce overall healthcare expenditures. In public mental health settings an emerging data base shows connecting our most vulnerable patients with serious mental illnesses to much needed resources in primary care can lead to effective treatment of chronic illnesses associated with cardiovascular disease. Receiving this care can lead to the reduction in morbidity and mortality responsible for the 25 year mortality gap. The major stumbling blocks to the full scale dissemination of these models include the siloed funding for mental health and primary care dollars, same day billing of a primary care and behavioral health visits, carved out mental health funding, and lack of coding and reimbursement models to pay for the collaboration and consultative portions of care

NO. 2 - MANAGEMENT CHALLENGES OF MULTIPLE MORBIDITIES: HIV, SUBSTANCE USE, HEPATITIS C AND SYPHILIS Presenter: Lawrence M. McGlynn, M.D. SUMMARY: To successfully diagnose and treat patients with HIV/AIDS, psychiatrists need to understand the complex biomedical aspects of AIDS as well as patterns of HIV infection in special patient populations. Good clinical care can frequently be impeded by the presence of subtle cognitive impairments, substance use disorders, or coinfection with Hepatitis C. New medications with new side effect profiles make treating HIV-infected persons with a psychiatric illness increasingly complex. This session will provide the most up-to-date information on diagnosis and treatment of cognitive disorders, the impact of prescription drug and methamphetamine use on care, new treatments for hepatitis c and syphilis, and the safest psychotropics to use with some of the new HIV medications. The session will include a lecture followed by an interactive question and answer period providing participants the opportunity to discuss individual clinical concerns.

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are some of the barriers to widespread dissemination and implementation of these models of care. While the inseparable nature of mental health and primary care is recognized by psychiatrists by virtue of their medical training, funding mechanisms will have to be developed to more fully engage them in this work. Models of funding are currently being tested nation-wide, funded by innovation projects provided in the Affordable Care Act, legislated changes in state Medicaid reimburse structures, private foundations and other resources to bridge the gap to more sustainable funding is implemented. The value added to a healthcare system when psychiatric and behavioral health resources are included is well proven and healthcare teams held accountable for outcomes, cost containment and patient satisfaction (the "Triple Aim"), will seek our expertise to design systems of care to meet these goals. Psychiatrists need to be prepared for these changes to assist in well-informed and meaningful ways. This symposium brings together national experts in the field to discuss integrating care in multiple settings and will provide a discussion of the evolving role of psychiatrists to meet the needs of these new models.

the expectation that the field of psychiatry take responsibility for the mortality gap.

NO. 1 - INTEGRATING CARE: A GLOBAL IMPERATIVE Presenter: Paul Summergrad, M.D. SUMMARY: The burden of comorbid psychiatric and general medical disorders will grow significantly over the next two decades as the burden of noncommunicable disease grows throughout the world. Integrative and collaborative care models will be essential given the relative paucity of psychiatrists in many parts of the world. This presentation will review the changing global burden of disease and the need for an international focus on mental health.

LESSONS LEARNED FROM WORKING WITH "REMOTE" PATIENTS

NO. 4 - IMPLEMENTATION OF VALUE-ADDED NONTRADITIONAL PSYCHIATRIC CARE IN THE ACO SETTING Presenter: Roger Kathol, M.D. SUMMARY: The delivery of psychiatric services will become a core part of medical care during the next decade as the health system tries to meet the triple aim of improving care, improving health, and lowering cost. Psychiatrists will need to re-orient their practices so that they deliver value-added psychiatric care in the medical setting. This presentation will identify specific areas of practice transformation that will maximize the value that psychiatrist bring to their patients, to systems in which they work, and to the health system. This will take place in new delivery organizations called accountable care organizations. _______________________________________________________ NOV 01, 2014

Chairs: Richard L. Merkel Jr., M.D., Ph.D., James L. Griffith, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify sociocultural and other structural issues that cause patients to be remote and that could contribute to doctor-patient conflict or misunderstandings; 2)recognize elements in the doctor-patient relationship that may contribute to distance and the potential for conflict or misunderstandings; and 3)acquire techniques for enhancing the doctor-patient relationship gained from experience working with remote patients. SUMMARY: Psychiatrists in general are having increased experience working with "remote" patients. We define remote as any structural dimensions that may cause a distance between the patient and the psychiatrist. These include, but are not limited to geographic, economic, and sociocultural differences that may contribute to doctor-patient conflicts and misunderstandings. Remoteness is a relative term and to some extent there are potential differences between all care givers and their patients. The presenters in this symposium have all had extensive experiences working with patients in which there are extreme differences leading to marked remoteness. They have learned from these experiences and will present what they have learned that can be applied to most all doctor-patient relationships, regardless of degree of remoteness. The participants in this symposium have had experience working with Nepali survivors of trauma on location, refugees in the United States, impoverished rural patients in Appalachia via Telepsychiatry, and patients with fundamental religious beliefs that are opposed to psychiatry. These experiences have enhanced their ability to work with patients where there is less remoteness and who are more typical of most psychiatric practices. They will present these lessons through this symposium. This symposium is sponsored by the Society for the Study of Psychiatry and Culture.

NO. 2 - PSYCHIATRY IN PARTNERSHIP WITH PRIMARY CARE Presenter: Jurgen Unutzer, M.D., M.P.H, M.A. SUMMARY: Integrated Care programs in which psychiatrists support and work closely with primary care providers to care for defined populations of patients with common mental health and substance use problems offer exciting new opportunities for psychiatrists to extend their reach and help improve the health of populations. Evidence-based integrated care programs are informed by principles of good chronic illness care such as measurement-based practice, treatment to target, and population-based practice in which all patients are tracked in a registry to make sure no one falls through the cracks. We will discuss such core principles of effective integrated care and give examples of psychiatrists working in integrated care programs with diverse patient populations. NO. 3 - THE ROLE OF THE PSYCHIATRIST IN ADDRESSING HEALTH DISPARITIES IN THE SMI POPULATION Presenter: Lori Raney, M.D. SUMMARY: Significant health disparities exist for the population with serious mental illnesses (SMI) and the role of the psychiatrist in addressing this inequality is changing. Many of the causes of premature mortality are preventable and psychiatrists will need new skills in addressing these issues and taking a population-based approach to managing patients. This presentation will include a discussion of these new skills and 28

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tions of this tool to improve task-sharing in cross-cultural, low income settings are discussed.

NO. 1 - APPALACHIA ON MY MIND: LESSONS FROM A REMOTE POPULATION Presenter: Richard L. Merkel Jr., M.D., Ph.D. SUMMARY: After many years of doing telepsychiatry consultations to Primary Care Practitioners in SW Virginia, working with patients from an Appalachian cultural context, it has become clear that skills gained in working with this remote population are important for working with all populations. The cultural context includes high levels of poverty, structural violence, distrust of outsiders, strict gender expectations, and fundamental Christian beliefs. Lessons learned from working with this population include the importance of pride in the face of poverty, the importance of gaining specific information about traumatic life experiences, the importance of not assuming motivation for behaviors that appear familiar, and the importance of appreciating the role of religious beliefs in the doctor-patient interaction. These will be described and discussed and examples of applications to less remote patients will be given.

NO. 4 - WHAT WORKING WITH REFUGEES CAN TEACH ABOUT THE DOCTOR-PATIENT RELATIONSHIP Presenter: Daniel Savin, M.D. SUMMARY: Twenty-two years of experience with refugees from diverse cultures has helped the presenter improve relationships with patients in general, teaching the importance of curiosity, patience, and flexibility. Curiosity, necessary with different cultural groups, can improve effectiveness with more typical patients. Patience, needed when listening to unfamiliar histories in a second language, can increase confidence in obtaining important information from English speaking patients. Flexibility is needed to adjust between an authoritative approach, helpful with a Cambodian refugee expecting medication, to a more even stance with an Iraqi refugee requesting social service assistance. This same flexibility is helpful in working with other patients from different cultural backgrounds, socioeconomic status and cognitive abilities. This presentation will illustrate how these attributes, so essential in working with refugee populations, facilitate the development a strong working alliance with all patients. _______________________________________________________

NO. 2 - LESSONS LEARNED FROM TREATING PATIENTS WHO HATE OR FEAR PSYCHIATRISTS DUE TO THEIR RELIGIOUS OR ETHNIC IDENTITIES Presenter: James L. Griffith, M.D. SUMMARY: In Emanuel Levina’s analysis of violence, a person feels violated, often responding with counterviolence, when continuity of self feels disrupted. Psychiatrists regularly evaluate patients who are fearful or disdainful of Psychiatry due to perceived threats to their religious or ethnic identities. Such encounters are difficult yet serve as a laboratory for learning experientially how to create clinical practices and settings that avoid identity disruption. This presentation illustrates how identity disruption can be avoided by: (1) active interest in the patient’s religious or ethnic identity before clinical intervention commences, (2) reducing physiological arousal, (3) minimizing ambiguity and uncertainty, (4) establishing personal contact, rather than categorical contact, with the disdainful patient, which typically shifts identity-driven fear or hatred “off-line,” enabling new, generative conversation to begin.

THE SMOKING CESSATION LEADERSHIP CENTER Chair: Steven A. Schroeder, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand the epidemiology of tobacco use in patients with behavioral health problems; 2) be familiar with the tools to help these patients quit smoking; and 3) justify the importance of smoking cessation for this population. SUMMARY: Smoking is the major cause of death and disability among patients with chronic mental illness and/or substance use disorders. Until recently, mental health professionals, including most psychiatrists, have placed a very low priority on helping smokers quit. Reasons for this inattention have included the sense that smoking is a relatively trivial issue for these patients, that patients don't want to quit, that they are unable to quit, that quitting may worsen their underlying mental health condition, and that making treatment settings tobacco-free will worsen patient cooperation. But as the evidence of the toll smoking exerts mounted--both for the patients themselves and for those exposed to second hand smoke-these attitudes have begun to change. In addition the arguments for not engaging in smoking cessation have been recently exposed as myths by researchers, especially psychiatrists and psychologists. This session will review the epidemiology of smoking among behavioral health patients, including recent declines in both prevalence and numbers of daily cigarettes smoked by those who have continued to smoke. It will summarize work by the Smoking Cessation Leadership Center of UCSF with SAMHSA and various health professionals, including the American Psychiatric Nurses Association. It will review a set of tools and practices that psychiatrists can use to increase the probability of both quit attempts and successful quitting. This session will conclude with a patient diagnosed with chronic mental illness who will describe how she was able to quit. _______________________________________________________

NO. 3 - THE TASK SHARING ADHERENCE AND SPECIFIC COMPETENCE RATING SCALE (TASC-R): A TOOL TO PROMOTE THERAPIST QUALITY IN TRANSCULTURAL, LOW-RESOURCE SETTINGS Presenter: Brandon A. Kohrt, M.D., Ph.D. SUMMARY: There is a gap of 1.2 million health workers needed to provide mental health services in low- and middle-income countries (LMIC). Task-sharing, the involvement of nonspecialist health workers to deliver mental health services, increasingly is being promoted to address this gap in the mental healthcare workforce. This presentation addresses the development of a tool to assess therapist quality in tasksharing initiatives. The tool is designed to be used with healthcare workers who are not mental health specialists, community health workers, and laypersons participating in mental health and psychosocial services. The tool is designed to facilitate selection of persons to be trained or to be trainers, evaluation of trainees and training programs, supervision in task-sharing initiatives, and evaluating fidelity in research trials of task-sharing. The strengths and limita-

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trained), working together with PCPs, empowering PCPs' skill set and using stepped approaches to care to be efficient-all of this is geared toward reaching the many folks who would rather see their PCP, live in rural areas, are nursing home residents, or otherwise live in areas less populated by psychiatric providers. Recently, a RCT of collaborative care by telepsychiatry was positive. A current study of consultation to primary care is a RCT that compares synchronous telepsychiatry (video) to asynchronous telepsychiatry (formerly store-and-forward; Reference). Clinicians considering a practice with telepsychiatry or who have begun using it can learn about the technology, models for providing care, and the 'ins' and 'outs' of administrative issues.

PUBLIC HEALTH IMPLICATIONS OF LONG ACTING INJECTABLE ANTIPSYCHOTIC MEDICATIONS IN THE 21ST CENTURY Chair: Jean-Pierre Lindenmayer, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify multiple barriers to the use of LAI experience by physicians in today's practice settings; 2)understand LAI treatment with an oral antipsychotic in patients with first episode psychosis with both neurocognitive and functional outcomes; and3)understand the economic impact on health care resource use after initiation of LAI antipsychotic medications. SUMMARY: Successful management of patients with chronic schizophrenia is complicated by a variety of real world factors, including low treatment adherence, comorbid substance abuse, unstable living conditions (e.g. homelessness), multiple hospitalizations and more recently contacts with the criminal justice system. In particular poor treatment adherence can have direct public health implications both for patients and society at large due to violent behaviors and incarceration with inadequate or inexistent treatment. Longacting injectable (LAI) antipsychotic therapies provide physicians with accurate monitoring of adherence and deliver predictable therapeutic concentrations continuously over several weeks and may represent better alternatives to oral treatments as they eliminate the need for potential conflicts over daily medication administration. However, LAI formulations are not widely used in public psychiatry practice even though they offer advantages with significant public health implications. _______________________________________________________

NO. 1 - ADMINISTRATIVE ISSUES (BILLING, LEGAL) RELATED TO TELEPSYCHIATRY Presenter: Nina Antoniotti, M.B.A., Ph.D., R.N. SUMMARY: The foundation for doing 'good' telepsychiatry parallels that of 'good' practice. Attention to the interpersonal, clinical, and administrative issues is a must. Two-thirds of telepsychiatric practice is similar to regular practice. There are some dimensions, though, regarding reimbursement, documentation and legal issues that need to be adjusted and/or added. This presentation reviews those for the APA member and provides resources from national organizations, other fields, and model programs to make this practice easier. Data in this area are limited due to inadequate study and proprietary matters, but that which is known and that which can be applied to telepsychiatry from other clinical settings will be reviewed. NO. 2 - ASYNCHRONOUS TELEPSYCHIATRY IN PRIMARY CARE Presenter: Peter Yellowlees, M.B.B.S., M.D. SUMMARY: The process of asynchronous telepsychiatry will be described including feasibility, reliability and validity testing, with a focus on how effectively this innovation can be incorporated in the virtual collaborative care model in primary care.

COLLABORATIVE CARE BY TELEPSYCHIATRY: MODELS (SYNCH AND ASYNCH CARE), TRAINEE ISSUES, INTERDISCIPLINARY ROLES, AND BILLING/LEGAL GUIDELINES Chairs: Donald Hilty, M.D., Peter Yellowlees, M.B.B.S., M.D. Discussant: Donald Hilty, M.D.

NO. 3 - TRAINEES AND INTERPROFESSIONALS IN A TELEPSYCHIATRY COLLABORATIVE Presenter: John H. Wells II, M.D. SUMMARY: Telepsychiatry and collaborative care are intersecting more often in various practice settings. Challenges arise when interdisciplinary teams with percieved and real differences in priorities attempt to communicate effectively and efficiently about patient care. Trainees such as psychiatry residents present an opportunity for overcoming barriers to interprofessional collaboration; however, though residents and other trainees are included in collaborative care and telepsychiatry in many programs, there is little guidance in the literature to assist programs wishing to integrate trainees. This presentation surveys available studies, guidelines, rules and practices involving interprofessional collaboration in telepsychiatry, and offers guidance based on experience integrating residents, psychologists, social workers and other professionals into a primary care collaborative with centralized care-management which heavily utilizes telepsychiatry to reach underserved populations.

EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) describe models of telepsychiatry (including asynchronous telepsychiatry) for collaborative care, including stepped care options; 2) understand the application of telepsychiatry applied to primary care, nursing homes and other settings; and 3) learn about the 'foundation' issues supporting telepsychiatry, including program development, interdisciplinary team roles and billing/ legal issues. SUMMARY: Telepsychiatry is effective based on many outcome studies comparing it with in-person psychiatric care and usual care in primary care settings (Reference). The foundation of its effectiveness is good administrative planning for program development, interdisciplinary team collaboration, and attention to billing/legal considerations. The model of collaborative care has made inroads in the provision of mental health services in the primary care setting for depression, anxiety/panic disorder and other disorders. Fundamental parts of this are psychiatrists who 'get' the primary care setting (often psychosomatic medicine 30

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residing within the hearer's realm of consciousness. Therapy consists of establishing dialogue among these beings and establishing their goals, desires, beliefs, and intents. Coalitions are formed among healthier voices resist unhealthier voices. More healing voices can be imported from the therapist. Puppets, drama, and masks are used in both individual settings and group settings for the performance of these dialogues. Theatre can ensue. We present a case series of individuals who had been given a psychosis diagnosis and who engaged in these approaches and whose voices became significantly less disturbing. Medication doses were significantly decreased over a period of 1 to 3 years. Within this series, we made the observation that many patients stopped reporting voice hearing to their psychiatrist, since it inevitably resulted in medication dose increases with the result of the occurrence of unacceptable side effects and no change in the voices. Our series of patients challenged the idea that increasing medication doses overcomes voices. We suggest that a place exists for psychotherapeutic techniques to fill the gap between what medication can do and the residual suffering remaining. There may also be a substantial number of people who hear voices and never come to psychiatric attention. Some of these people fall into the category of religious or spiritual experiences, some have been raised in cultures in which hearing voices is expected and considered normal, and others may have spontaneously learned to manage their voices without medical intervention.

NO. 4 - DELIVERY OF PSYCHIATRIC SERVICES TO NURSING HOME RESIDENTS USING TELEPSYCHIATRY Presenter: Terry Rabinowitz, M.D. SUMMARY: Depression and other psychiatric conditions are common among nursing home residents. These conditions are often a cause of suffering and in addition, may adversely affect the outcome of co-occurring non-psychiatric conditions. Despite the high rates of occurrence, many of these conditions go undetected, untreated, or misdiagnosed, often because psychiatrists are not available or are not interested in visiting nursing homes—this is especially true in rural areas where long distances between patients and potential care providers make it difficult or impossible for patients in need to get appropriate services. In addition, many psychiatrists are unwilling to spend many hours on an individual consultation due to poor reimbursement rates. This talk will address psychiatrist shortages among nursing home residents and how a telepsychiatry approach is an acceptable, efficient, and cost effective alternative to face-to-face care for this vulnerable and underserved population. _______________________________________________________

WORKING PSYCHOTHERAPEUTICALLY WITH PEOPLE WHO HEAR VOICES: CROSS-CULTURAL AND NARRATIVE PERSPECTIVES Chair: Lewis Mehl-Madrona, M.D., Ph.D.

NO. 1 - HISTORICAL PERSPECTIVES ON VOICE HEARING AND THE CURRENT INTERNATIONAL MOVEMENT Presenter: Josephine A. Conte, D.O. SUMMARY: The literature of antiquity would suggest that voice hearing was relatively more common than today. Famous figures including Moses, Abraham, Ulysses, Achilles, and others appear to have been hearing the voices of God or the gods. Within indigenous cultures spirits and ancestors have spoken to the living for as long as anyone can remember. Ancient pictographs and other drawings are consistent with this observation. In more contemporary times, Albert Einstein and Thomas Edison admitted to hearing voices. Apparently, the phenomenon is widespread and more common than contemporary psychiatry suspects. Hearing Voices is the one symptom for which a diagnosis of a psychotic disorder can be made without any other signs or symptoms. Thus, voice hearers would be reticent to share their experiences. However, in the last 20 years, an international movement has arisen to normalize the hearing of voices. This presentation closes with a description of that movement and its history.

EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify three stances toward the ontological status of voices, including the indigenous, the biomedical, the psychoanalytic, and more; 2) describe three techniques for helping clients learn how to manage their voices, thereby suffering less and being less fearful; 3) describe three different types of voice experiencing (persecutory, spiritual, ancestral, guiding, etc.); 4) explain why voice hearers might be reluctant to tell their psychiatrist/doctor about this phenomenon; and 5) describe three limits of medication for managing voices. SUMMARY: Debate exists about what voices are. An international movement has arisen that proclaims the normalcy of voices and is called Hearing Voices International and Intervoice. Branches exist around the world, including Voices Victoria, Voices Ireland, and the like. In this panel, we explore the implications of this movement and discuss our own experiences of working psychotherapeutically with people who suffer from the voices they hear. We also discuss our experience with people not identified as psychiatric patients who hear voices they find uplifting and comforting, mostly from indigenous cultures in North America and Australia. We discuss the varieties of ontological perspectives on voices, including indigenous views that grant them full ontological status at one end of the spectrum to the biomedical view which dismisses them as random products of diseased brains at the other end of the spectrum. We review the neuroimaging studies of voice hearers and suggest that these findings are most consistent with the view that voice hearing is an ordinary phenomenon and that the problem lies in the frontal lobes where the status and meaning of voices are interpreted and experienced. We present an approach that integrates the perspectives of indigenous cultures and that of contemporary dialogical self theory in which voices are treated as independent, ontological beings

NO. 2 - TECHNIQUES FOR WORKING WITH VOICE HEARERS Presenter: Barbara Mainguy, M.A., M.F.A. SUMMARY: In this portion of the symposium, we present the techniques used with voice hearers. First comes dialogue with and about the Voice. We aim for all voices to have names and to have appearances. A voice is best associated with a visual tag. Voices are often interviewed to learn their origins, intents, desires, beliefs, strengths, and weaknesses. The interview is conducted by the therapist until the client can learn to dialogue with his or her own voices. Once voices are identified, the question is raised as to which voices are useful/helpful and in what contexts. Clients learn to con31

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struct dialogues with the voices. Often these dialogues begin as performances in which puppets take on the voices. Alternately masks or other people can be used (in a group setting). Once voices are identified, coalitions can be formed among healthy voices to stand up to mean or demeaning voices. "Bad" voices are often challenged to prove that they have power, which inevitably they don't.

nosis and monitoring of mental health symptomatology; and 4) be able to describe the results of validation studies using these methods in different psychiatric patient populations when compared with gold standard assessment: SCID, HAMD, CESD, and PHQ9. SUMMARY: Mental health measurement has been based primarily on subjective judgment and classical test theory. Typically, impairment level is determined by a total score, requiring that all respondents be administered the same items. An alternative to full scale administration is adaptive testing in which different individuals may receive different scale items that are targeted to their specific impairment level. This approach to testing is referred to as computerized adaptive testing (CAT) and is immediately applicable to mental health measurement problems. We have developed CAT depresssion, anxiety and mania tests based on multidimensional item response theory (IRT), well suited to mental health constructs, that can be administered adaptively such that each individual responds only to those items that are most informative for assessing his/her level of severity. The shift in paradigm is from small fixed length tests with questionable psychometric properties to large item banks from which an optimal small subset of items is adaptively drawn for each individual, targeted to their level of impairment. For longitudinal studies, the previous impairment estimate is then used as a starting point for the next adaptive test administration, further decreasing the number of items needed to be administered. Using decision theoretic methods we have also developed a computerized adaptive diagnostic (CAD) screening test for major depressive disorder called the CAD- MDD. The CAD-MDD provides a binary classification which maximizes association with a clinician-based DSM-V diagnosis of MDD and estimates the confidence in the corresponding classification. Results to date reveal that depressive severity can be measured using an average of only 12 items (2 minutes) from a bank of 400 items, yet maintains a correlation of r=0.95 with the 400 item scores. Similar results are seen for anxiety and mania. Using an average of only 4 items (< 1 minute) the CAD-MDD has sensitivity of 0.95 and specificity of 0.87, where for the same subjects, sensitivity for the PHQ-9 is 0.70 with similar specificity.

NO. 3 - OUTCOMES OF PSYCHOSOCIAL APPROACHES TO HEARING VOICES Presenter: Lewis Mehl-Madrona, M.D., Ph.D. SUMMARY: In this portion of the symposium, we present outcome data from our series of cases in Maine and Vermont, USA. Clients participated in either individual or group sessions. Using an intent to treat perspective, 34% of people did not achieve any benefit. Eighty-seven percent of those people did not complete four sessions. Their mean number completed was 2.5. Those who benefited completed a mean number of 14.1 sessions. Pre-treatment data was available for the Positive and Negative Symptom Scales, the Clinical Global Inventory, the Hamilton Anxiety and Depression Scales, and the MYMOP2. Statistically significant reductions in ratings of severity of symptoms occurred, with similar improvements in rated quality of life. Positive symptoms lowered statistically significantly compared to baseline measurements. A total of 40 clients began the treatment process. Other factors besides these techniques may also be important, including the quality of the relationship with the therapists. NO. 4 - WHEN HEARING VOICES IS NORMAL OR TRANSCENDENT Presenter: Magili C. Quinn, D.O. SUMMARY: We complete the symposium with a discussion of those circumstances in which hearing voices is normative or transcendent. Within indigenous cultures, voices represent the whispers or spirits or ancestors. All aspects of nature are granted ontological status. Trees, animals, rocks, mountains, rivers, all can speak. The culture expects its members to be able to hear. A variety of spiritual traditions recognize and celebrate those who can hear voices as being close to God or the Greatest Being or able to receive communication from angels or spirits. We propose that psychiatry could do well to revise its assessment of hearing voices as always pathological. We present case studies of healthy people who report hearing voices that are helpful to them, inspiring, and even transformative. If hearing voices is normalized, it becomes easier to talk about hearing voices and to work with those who hear voices. _______________________________________________________

NO. 1 - THE FUTURE OF PSYCHIATRIC MEASUREMENT Presenter: Robert Gibbons, Ph.D. SUMMARY: The CAT-MH, is a suite of three adaptive tests for depression, anxiety, and mania, and a diagnostic screening test for major depressive disorder (CAD- MDD) developed as part of an ongoing program of research funded by the NIMH. The CAD-MDD produces a remarkably accurate screening diagnosis of depression. The three computerized adaptive tests produce continuous severity scores that can be used for both assessment and monitoring. The paradigm shift between traditional screening and assessment tools and those associated with these tests is that they begin with a large bank of items (1008 psychiatric symptom items) and adaptively administer a small and statistically optimal subset of the items (on average 12 items for each of the three CATs and 4 items for the CAD-MDD). Nevertheless, each of the CATs maintains a correlation of close to r=0.95 with the entire bank of items for each test (389 depression items, 431 anxiety items, 88 bipolar items).

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THE FUTURE OF PSYCHIATRIC MEASUREMENT Chair: Robert Gibbons, Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) understand item response theory and the bifactor model as it applies to measuring psychiatric disorders; 2) understand computerized adaptive testing as it applies to measuring psychiatric disorders; 3) be able to discuss how modern psychometric measurement can improve the diag32

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and widely available tools for integrated assessment and recovery planning that are already available for general system use. First, Dr. David Mee-Lee will describe application of the newest (2013) version of the ASAM Criteria for substance related and co-occurring disorders (Dr. Mee-Lee is the lead developer of that document) to organizing personcentered and integrated program/service matching and recovery planning approaches for individuals with complex mental health and substance use needs. Second, the symposium will discuss the newest applications of the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS 2010) (presented by Dr. Wes Sowers, the lead developer of that document) to the process of integrated assessment, level of care and service matching, and recovery planning. Finally, Dr. Kenneth Minkoff will describe an integrated recovery planning template that has been developed and disseminated in system wide projects for developing recovery oriented integrated services using the Comprehensive Continuous Integrated System of Care (CCISC) framework in over 30 states. In order to demonstrate the application of these tools, participants will be provided with a complex case example, assisted to use the tools, as well as their own clinical judgment, to determine appropriate interventions in the context of integrated recovery planning for that case, and then participate in a discussion to explore the current state of the art and science of assessment and recovery planning for individuals with co-occurring disorders and the clinical challenges that emerge in addressing their needs.

NO. 2 - VALIDATION OF COMPUTERIZED ADAPTIVE TESTING IN A COMMUNITY Presenter: Eric D. Achtyes, M.D., M.S. SUMMARY: This study sought to validate the utility of the diagnostic screening test CAD-MDD as well as the CAT-MH suite of tests (CAT-DI, CAT-ANX, and CAT- MANIA) for assessing cross-cutting psychiatric symptom severity in a community sample of adult psychiatric outpatients. One hundred fortyfive individuals, aged 18-70 years, with a range of psychiatric diagnoses who sought access to care at Pine Rest Christian Mental Health Services, a large, free-standing psychiatric treatment facility located in Grand Rapids Michigan, as well as healthy controls, were evaluated using the above measures in addition to gold-standard diagnostic and severity scales including the SCID for DSMIV-TR, CES-D, PHQ9, HAM-D25 and GAF. The level of patient satisfaction with computerized testing was also measured. Results from this cross-sectional, prospective study will be discussed. _______________________________________________________

INNOVATIONS IN INTEGRATED ASSESSMENT, SERVICE MATCHING, AND RECOVERY PLANNING FOR INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE DISORDERS Chair: Kenneth Minkoff, M.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) identify the clinical principles of integrated recovery oriented practice with individuals with cooccurring conditions that permit development of appropriately matched integrated recovery plans; 2) become familiar with the flexible array of services that can be provided for individuals with co-occurring disorders in an integrated continuum of care; 3) demonstrate the ability to use the newest versions of the ASAM Criteria (2013) and Level of Care Utilization System (LOCUS 2010) as frameworks for assessment and person-centered recovery planning; and 4) practice applying the principles presented, using a recovery oriented and integrated tool as a mechanism for organizing and structuring integrated recovery planning. SUMMARY: Individuals with co-occurring mental health and substance use disorders represent a population with poorer outcomes and higher costs in multiple domains, and often presenting in complex crisis situations with complex needs requiring accurate assessment to determine appropriate program and service matching in the context of developing an integrated person-centered recovery plan. Despite the frequency with which this type of clinical situation occurs in adult and child service settings, most systems do not have an organized and systematic approach to help clinicians with the process of integrated assessment and recovery planning throughout the continuum of care. This symposium explores the issue of integrated assessment and recovery planning for individuals with psychiatric and substance use disorders, and other complex primary health and human service needs, identifies the clinical principles of successful multi-problem, multidimensional assessment and intervention within a recovery oriented framework of service delivery, and then illustrates structured approaches for application of those principles in real world systems to real world clients. These principles are then illustrated through a description of the most common

NO. 1 - PRINCIPLES OF INTEGRATED ASSESSMENT AND RECOVERY PLANNING FOR INDIVIDUALS WITH COOCCURRING DISORDERS Presenter: Kenneth Minkoff, M.D. SUMMARY: Dr. Minkoff will begin with a brief outline of core evidence based principles of successful assessment and intervention for individuals or families with co-occurring mental health and substance use conditions, as well as other complex needs. These principles emphasize the importance of identification of multiple primary issues or conditions, focusing in a recovery framework on the person’s goals for a happy, hopeful, and productive life, identification of previous periods or efforts to make progress in the context of a strength based longitudinal assessment, and then application—for each issue— of stage-matched, skill-based learning, in small steps, with big rounds of applause for each piece of progress, to help the individual learn how to address multiple issues over time. Within the context of these principles, the presentation will illustrate how to apply this approach to real world clinical situations, and to use a simple template to document integrated stage-matched recovery. NO. 2 - A COMPUTER ASSISTED APPROACH TO PERSON CENTERED PLANNING: THE LOCUS M-POWER PLANNER Presenter: Wesley E. Sowers, M.D. SUMMARY: Person centered, collaborative planning has been embraced by transformation minded administrators and is attractive in theory to most clinicians. A major obstacle to real life implementation has been hampered by time and productivity constraints, and even those clinicians who are its most fervent advocates find it difficult to develop a highly individ33

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ualized plan with the full involvement of the service user. LOCUS is a needs assessment tool which provides a dimensional quantified profile of client needs to assist service intensity decisions. Using this same profile developed in conjunction with the service user, the LOCUS M-POWER Planner translates the identified areas of need into a treatment plan format, allowing both suggested menu seletions and customized inputs to the plan. Working with the client in front of the computer facilitates the plans development while enhancing the therapeutic relationship. The M-POWER planner will be described and its utility will be discussed.

times the general population), mental illness (twice the general population), and somatic health issues that contributes to poor treatment adherence, and health risks for the general public. This symposium will address how the comorbidity of mental and substance abuse disorder impact the risk for HIV/AIDS and potential treatment approaches. Dr. Lawson will provide an overview and discuss the problem of comorbid mental disorders and their treatment in opiate abusing African Americans at risk for HIV/AIDs. Dr. Smith will discuss the impact of the triple whammy in the African American community supplemented with video clips to identify treatment needs. Dr. Nwulia will discuss the impact of mood disorders on HIV/AIDS and strategies for recognizing depressive disorders in this population. Dr. Springer will show the impact of HIV positive released inmates on the community and provide evidence that treatment of substance use disorders improves HIV treatment outcomes and prevents the development of new cases.

NO. 3 - USING ASAM CRITERIA'S MULTIDIMENSIONAL ASSESSMENT TO DEVELOP PERSON-CENTERED RECOVERY PLANS Presenter: David Mee-Lee, M.D. SUMMARY: This presentation will improve participant’s knowledge in providing focused, targeted, individualized behavioral health treatment. It will provide the opportunity to practice assessment and priority identification, and translate that into a workable, accountable treatment plan that promotes recovery. Reference will be made to The ASAM Criteria assessment dimensions to help organize assessment and treatment data. _______________________________________________________

NO. 1 - IMPACT OF HIV ACCOMPANIED BY SUBSTANCE ABUSE AND MENTAL ILLNESS IN THE AFRO- AMERICAN COMMUNITY Presenter: David Smith, M.D. SUMMARY: In working with HIV infected patients for fourteen years at an HIV specialty clinic, I have seen numerous Afro-American patients with the “triple whammy.” There are well-established prejudices within the Afro-American community against mental illness and among males, including the phenomenon of nondisclosure of sexual preference, frequently referred to as “down low.” Of further relevance is the explosion of methamphetamine and opiate dependence which often results in misdiagnosing mental health disorders. With the help of videotaped interviews I will illustrate effective interventions in this population. The role of the psychiatrist and mental health team in the HIV setting can eliminate barriers to effective HIV care and prevent morbidity and death from the virus. Discussion of stigma , disclosure , recovery ,spirituality and appropriate usage of medications for mentally ill patients are all key to effectively treating all three conditions.

TREATING THE TRIPLE WHAMMY: SUBSTANCE ABUSE, MENTAL HEALTH AND HIV/AIDS Chair: William B. Lawson, M.D., Ph.D. EDUCATIONAL OBJECTIVE: At the conclusion of the session, the participant should be able to: 1) appreciate how mental health and/or substance abuse complicate prevention and treatment of HIV; 2) understand how under-diagnosis of mental disorders especially in minorities contribute to a continuing AIDS epidemic; 3) develop strategies for distinguishing the symptoms of AIDs from major depression and how best to treat the comorbid depression; and4) recognize the impact of substance abuse the spread of AIDS. SUMMARY: Drug abuse disorders commonly co-occur with other mental disorders. People addicted to drugs are roughly twice as likely to suffer from mood and anxiety disorders, and vice versa. Moreover substance abuse and other mental disorder are each risk factors for HIV/AIDS. Often all three can cooccur together, contributing to the HIV/AIDS epidemic, and poor treatment adherence. This triple whammy is especially problematic for certain populations. African Americans and other ethnic minorities are less likely to have mental and substance abuse disorders recognized and treated which may contribute to their greater likelihood of contracting HIV/AIDS and to have a poorer outcome. The war on drugs and deinstitutionalization created a "perfect storm" in which the correctional system saw an increase in nonviolent offenders with complicated treatment needs, increased risk for HIV/AIDS, hepatitis, and social and health concerns for the public after the offender is release. Those involved in the justice system have increased rates of substance abuse (four

NO. 2 - COMORBID MOOD AND SUBSTANCE ABUSE DISORDERS IN AFRICAN AMERICANS UNDER COURT SUPERVISION Presenter: William B. Lawson, M.D., Ph.D. SUMMARY: Mental and substance abuse disorders are independent risk factors for HIV. Mood and substance abuse disorders are also common in correctional systems. This population is especially at high risk of acquiring HIV/AIDS and spreading the disease to the community. Moreover African Americans are overrepresented in the correctional system and this triple whammy may explain the increasing rates of HIV/AIDS. For this reason we examined the incidence of mood disorders in a population of African American opiate users. More than half had major depression or bipolar disorder and only half were receiving evidence based psychotropic medications. Improved access to care of this high risk population is essential to reducing the toll of HIV/AIDS in the African American community.

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NO. 4 - MENTAL ILLNESS NEGATIVELY IMPACTS HIV TREATMENT OUTCOMES AMONG HIV+ CRIMINAL JUSTICE POPULATIONS Presenter: Sandra A. Springer, M.D. SUMMARY: One in 100 adults in the United States are incarcerated, with one in 31 under community supervision in parole or probation. In the incarcerated population, HIV and psychiatric disorders (PDs) are concentrated and syndemic, with each negatively impacting the outcome of treatment and prevention efforts. Axis I PDs and SUDs are concentrated among prisoners within the correctional system (CS) with 2x and 9x (65% vs. 9%) prevalence, respectively; similarly, the prevalence of people living with HIV (PLH) is 3x greater than the general population. CS-involved PLH have higher rates of PDs than those without HIV, and PDs are higher among this population compared to the community. Dr. Springer will present findings from her NIH-funded research of HIV+ prisoners and the effect of PD on post-release HIV outcomes and need for better pre-release psychiatric screening to improve adequate transition to the community.

NO. 3 - MAJOR DEPRESSIVE DISORDER COMORBIDITY IN INNER CITY AFRICAN AMERICANS Presenter: Evaristus Nwulia, M.D., M.H.S. SUMMARY: Objective: To improve our understanding of salient community-specific factors associated with Major Depressive Disorder (MDD) comorbidity in HIV, we conducted a retrospective review of medical records in an inner-city community clinic of predominantly low-income African American (AA) patients. Method: A cross-sectional study of 158 AA HIV-infected individuals screened for MDD. Result: The prevalence of past year MDD was 38% and 49% of the population had a lifetime history of trauma. Individuals with MDD had significantly (P