As we discuss mental health parity on a national level and with state legislators and APA's advocacy efforts - and as members of Arizona Psychiatric Society, we are all too familiar with the many Arthurs aka Jokers who fall through the cracks of the system and succumb to their mental illnesses to the point of no return. Like Arthur, they panic when they run out of their medications and fear the return of their psychosis. These persons are too mentally frail to advocate for themselves, and just like the Joker, often have family members who are entrenched in their own mental health challenges - hence have no one to advocate for them either. So this is an important time, whether it is the 1980s Gotham City or 2019 present day Arizona, where we as psychiatrists can be the fate and gatekeepers of our patients' mental health, as sometimes their one and only hope. Under the leadership of our current APS President Dr. Don Fowls and his strong passion for mental health parity and advocacy, this is an important time for us to recognize the role each one of us can play in aligning conversations with other mental health agencies in the state, including faith-based religious organizations, families, and communities that can provide support to persons with mental illness.

On that note, I wish you all a very Happy Thanksgiving.

Gurjot Marwah, MD, Guest Editor

Don J. Fowls, MD

President, Arizona Psychiatric Society

As psychiatric physicians, individually, and collectively, as a Society, we see the opportunity ahead of us to engage with our partners and our community on important issues that impact access to care by our patients and the impact to improved mental health that we can make as psychiatrists.  If you missed our special September Newsletter, with information on parity efforts, how you can become engaged, including a Call for Stories being compiled by the Arizona Council of Human Service Providers, CLICK HERE for that important information.   We have also engaged with a broad array of associations and stakeholders in our community in a collaborative effort to make parity more real than it is today, who have shown great interest. It also includes providing data that demonstrates the value of good behavioral health care.  I hope you enjoy the contributions of several of our members in this edition. They are well-worth reading. Two I wanted to highlight. Dr. Gurjot Murwah makes important points about how we as psychiatrists can be a constructive voice in the community when it comes to issues like gun violence. This is so important and reminds and encourages us to get off the sidelines and out into the open community to help and communicate what we can. And the interview with Dr. Ed Gentile and his wife is very wonderful! Ed is someone who has been both a provider and managed care medical director and by example has done so much to represent the goodness of many people on both sides of the fence. There are many issues to address for sure, but it's always nice to hear about someone who has risen above the fray and been a constructive force through it all.  

Premium Corporate Sponsor 2019-2020  

APS Meet Your Member Profile of Edward Gentile, DO, DFAPA

By Jason Curry, DO, Guest Interviewer

Doctor Ed Gentile is a remarkably bright and sanguine figure. It was Jasleen's and my fortune to spend an evening with him and his wife, Deborah, walking amongst the massive murals in downtown Tucson, while interviewing Ed about his career and thoughts on the medical complex.

The walk amongst the murals was befitting. There has been a growing movement in the world of murals known as "Environmental Graphics" - a movement represented in many Tucsonan murals. Environmental graphics is a step beyond painting a beautiful piece of art directly on a wall. It is executing that beautiful work in a fashion that enhances the natural aesthetic quality of its surrounding environment: buildings, landscape, plants, road/walkways, etc.

Is the mural then made beautiful by its connection to the space? Or, is the cityscape made beautiful by the mural? The answer to both is "YES." Such is the career of Arizona's latest APA Distinguished Life Fellow, Ed Gentile, DO. His career is artistry in its own right, yet it too has honored and enhanced the medical landscape to the betterment of countless patients.

In his career, which took a turn very early on from pathology to psychiatry, Ed has been a stalwart promotor of patient advocacy, understanding and curiosity. This interplay of caring and curiosity was evident immediately upon our arrival at the first mural.

This mega mural "spoke" to Ed. He was reminded of his journey from PA out to AZ, which would become his home for 30+ years. A graduate of Philadelphia College of Osteopathic Medicine (1978) and completing residency at the Medical College of Pennsylvania (1985) Ed had to overcome a lot of barriers to become a psychiatrist, especially as a DO in the 70's & 80's, at a time when conceivably stigma against mental illness was worse and notable discrepancies in reimbursement existed between the disciplines in medicine.

Before the venture out to AZ became permanent, Ed spent time working as a general practitioner in WV as part of his National Health Service Corps scholarship payback and later learned the inner workings of a new technology in his academic faculty position in the mid-1980s in Philadelphia - that new "technology" - "managed care."

In 1976 Ed met Deborah. As he gazed up at the mural featuring two wild-hearted bicycle riders cocreating a story through the desert landscape, Ed shared how for the couple "moving out here was an adventure: it felt like landing on Mars." The Sonoran terrain was like an alien planet to Ed, who grew up in Rhode Island and had acclimated to all rich and beautiful vegetation typical of the East Coast. "I had never seen the desert in my life...but as I got to know the desert - it's changing appearance with changes in season, in light - it's changing smell after a rain - it began to feel like HOME."

Ed is grateful to have taken this journey with his beautiful wife and starting their family. His daughter Hilary was 7 at the time the couple moved, and his younger daughter, Brooke, was born in Arizona. Now, his daughters are fully grown. At the foot of the mural, Ed remarks on how these two have their own unique blending of methodical and adventurous natures.

Initially, Ed started working in Tucson in his own blended outpatient and inpatient practice. Later, when he began work with Community Partners of Southern Arizona, he was one of the rare medical providers who held Saturday and afterhours clinics to see his private practice outpatients. The transition to CPSA was an opportunity to continue impacting patient wellbeing while nurturing his own enthusiasm, "I trained in the public sector. I missed that interdisciplinary approach."

In our walk over to the next mural Ed explains how overtime he slowly closed his private practice, while returning to public sector work in what became a 22 yearlong clinical and administrative job with CPSA.

In his own words: "It's exotic - beautiful. It evokes a sense of passion. I'm not a tequila drinker," Ed says pointing to the agave crown atop the head of the ethereal feminine figure, "but I have a passion for what I do."

This mural reminds Ed of the thousands of patients he has encountered at his work in our local community. "What do they want, and how do we help them met their needs?" The confident gaze of the goddess reminds Ed of his appreciation to these many patients who have entrusted him with their "stories, their secret longings and their lives." With these thoughts it is a short but solemn procession to our next mural.
Ed feels honored to be recognized as a Distinguished Life Fellow. He admits, "It wouldn't have happened without Teri. She's a gem." He likens the figures in the mural to the duty bestowed upon all of us to pass down the tradition and share it with the next generation.

Much of his work at CPSA was not only to improve the care delivery systems for patients, such as by collaborating development of assertive community treatment teams, but to learn from and teach other providers how to perform more "nurturing" care. There is no hesitation in his praise for his former teams and coworkers. Ed instructed me that if you are working with young trainees/physicians, "you have to help sustain them." We had to leave: the train is here.

Tucson is graced with many murals downtown, so the walk from Borderlands to the next selected mural was littered with scores of interceding works. However, the next mural brings Ed palpable joy. He says, "It reminded me of the Saturday Evening Post."

This surreal play on running from bulls features a young boy both delighted and terrified by the fantasy creatures stampeding towards him. It looks to Ed like the boy is "having the greatest time."

In medicine Ed explains, "I feel very conscious of not wanting to make a mistake." This has long been a governing ethos in his work. In recent years it has taken on new light after Ed left CPSA to briefly work as the regional medical director for Southern AZ at Community Bridges and then presently as a Behavioral Health Medical Director for UnitedHealthcare Community Plan. His work here is heavily involved with the care management and care advocacy of individual persons as well as larger populations.

At the same time that Ed craves the carefree exuberance of childlike pursuits, like running from snorting papier-mâché figures, ostensibly filled with delicious candies, he is mindful of the ultimate responsibility his work holds. His reflections are both micro- and macroscopic. "Am I doing the right thing? Are other doctors doing the right thing? Did I add to the administrative burden of the work? Have we done ourselves any favors [with EMRs]?"

He dreams of a future opportunity to see medicine "using data in a real-time and beneficial way...I'd love to come back in a few hundred years and see the state of psychiatry or whatever they call it at that time. Will they think we were barbaric? Will they think [our] new learning brought the needed promise?"

Like Ed I am sure we all hope the answer to his last question is again: "Yes!" It's a short journey to our last mural. Ed takes a brief detour to offer a warm meal and kind words to a homeless gentleman laying on a park bench. 

When Ed is conversing at this mural, I cannot tell if he is speaking about the mural or about life. "What's your secret? Did you see something? Why the mask?" The mural itself is a feminine figure whose knowing eyes are played opposite a face made expressionless by a bright red mask and hands held steady in tranquil repose before the mouth and nose.

He echoes back to his gratitude for his patients, and in this appreciation, he expresses great intrigue and awe at the capacity for human healing; "how resilient and really just extraordinary our patients are."

In front of this masked woman and her turquoise stare, Ed also expresses gratitude for his family: an elemental part of his being that he clearly loves beyond his vocation. He remarks of how they all sacrificed for one another, and how he was so lucky to go back to school to receive his MBA at the UofA - at a time when his eldest was also enrolled in her own undergraduate studies.

Our evening with the Gentiles ends with joyful exchanges and the hope to meet and share again. In the future Ed is looking forward to more "carefree adventures", perhaps in transitioning toward retirement, and hoping to see more involvement in the APS and APA, especially by other Tucsonan psychiatrists.

Thank you for the adventure Ed. Thank you for your artistic dedication to the craft of patient care. Congratulations on a distinction well deserved - our newest Distinguished Life Fellow. 

Private practice opportunity in Tucson, Arizona in an overhead sharing arrangement with two other psychiatrists, a DNP, and a master's level therapist.   Contact Shari at 520-795-0309 

Gurjot Marwah, MD, FAPA
Past President, Arizona Psychiatric Society

Private Practice Psychiatrist

Founder of Healing Minds, PLC

Tempe, Arizona

In a country with a burgeoning population that is being diagnosed with Type 2 Diabetes, like the rest of the developing countries in Latin America, one thing that sets Cuba apart is a passionate focus on using primary care setting as a vehicle for imparting diabetes prevention education and care to the population, whether as regular monitoring of their blood glucose levels in the consultorios (the free local clinic assigned to all Cubans), and also with frequent in-home visits by the primary care team to assess life style and give dietary recommendations, a pop-in visit during dinner time by their PCP who usually lives in the neighborhood and knows the family well is fairly common. This model's success with its people is being repeated in other Latin American countries. Doctor-to-patient ratio in Cuba is among the world's highest at 127 persons per  physician; surprisingly 61% of all physicians in Cuba are women. There are 150 hospitals; 450 community polyclinics; and an astounding  13,131 neighborhood family doctor-and-nurse offices which provides primary care including  diabetes education.  

    

Dr. Garcia Herrera, senior Researcher and expert in Cuba in Angiology, talks about the Cuban invention, Heberprot-P, a unique therapy that lowers the risk of amputation in Diabetics by 70%.

In October 2018, I got to witness this unique model first hand in Havana - as a member of the "unofficial " US delegation to Cuba, which included two podiatrists, two cardiovascular surgeons, a nephrologist and a psychiatrist, along with a US congressman - all there to learn how healthcare is imparted in our neighboring country, isolated politically and emotionally, not culturally, with a strict trade embargo since the 1950s Cuban missile crisis. A country only a 45-minute flight from Miami, Florida where time seemed to be in no rush, like stepping into another era, where there are no fast food joints; no malls; where kids don't know what Coke and Pepsi are; where internet access is extremely limited to the general public and mobile phones are a rarity.  Yet among the beautifully restored colorful Spanish colonial and baroque style buildings of old Havana, it was a heartening sight to see kids playing and running around in the narrow streets, as their mothers chatted from across their fourth floor small balconies, casually keeping an eye on the kids and each other, the men aggregated in their own groups sitting on rundown plastic chairs in the street in front of their small apartments, their loud spirited laughter and conversations oblivious to any discomfort from the hot humid air, as much an audience, from the Atlantic Ocean close by. The old city of Havana was getting ready to celebrate its 500th year birthday in 2019 with welcoming tourists from all over the world.  Including us.  

 

Our team got to see how Cuban government is implementing a healthcare initiative to manage the complications of Diabetes with new drugs. Foot ulcers are a serious complication of diabetes. In diabetes, there is decreased production of epidermal growth factor, hence decreased oxygenation and impaired blood flow to the peripheral organs slows wound healing on feet. Cuban researchers have developed a medication called Heberprot-P which when applied topically or injected directly into a foot ulcer has been successful in patients with diabetes to reduce the risk of foot amputations by 70%. With 73,000 foot amputation's occurring in the US alone each year, mostly in patients with diabetes, the Cubans were making a case for improved US - Cuba relations, to loosen the strict diplomatic embargo in place since the 1950s, to open access to the US patient population with Diabetes to Heberprot-P.  Heberprot is an innovative product developed in Cuba and now available in 23 other countries containing recombinant Human epidermal growth factor for peri- and intra-lesional infiltration; evidence reveals it accelerates healing of deep and complex ulcers, both 

ischemic and neuropathic, and reduces diabetes-related amputations.  Heberprot-P is a unique therapy for the most complicated and recal citrant chronic wounds usually associated with high amputation risk.  

Where it shows Heberprot-P is being injected in most primary care clinics in Cuba to prevent loss of oxygen  and eventual amputation in diabetics who have foot ulcers.

Local injection in complex diabetic wounds has demonstrated a favor able risk-benefit ratio by speeding healing, at the Diabetics speciality clinic, where a team of mostly women physicians demonstrated to us the ease with each they injected the patients at high risk. In a country where medical care is free to all its citizens, even the latest medications like Heberprot-P is easily available with no copay, and no prior authorization. All that is needed is a referral by their primary care doctor. 

 

Next stop was a visit to the Center For Genetic Engineering and Biotechnology in the heart of Havana. It  was a brief refresher to our US medical team to all the cutting edge therapies, medications being engineered in Cuba and their success, some unheard of in the United States. 

Innovations in Diabetic Care with an 

educational  exchange with various Cuban scientists whose work has been central to the formulation of innovative approaches to diabetes care and its complications, such as medications for diabetic foot ulcers developed at the Genetic Engineering and Biotechnology Center. 

 

Day 3 of my stay was  Educational Exchange at a Comprehensive Diabetes Care Center in Havana to observe patient education and treatment. We interacted with Cuban health professionals and patients, as the endocrinologist injected Heberprot-P at the edges of weeping wounds on the feet, talked of care and management.

	From top to bottom, week 1 before injecting Heberprot P, week 7 after injection and week 11 where the foot ulcer is healed.

Our US team had a working  lunch at a private in home restaurant called Paladares with the director of the  National Endocrinology Institute of Cuba, where we exchanged about the epidemiology of diabetes and related conditions in Cuba and the USA, as well as population health approaches to management and patient education.

 

Each year the number of people diagnosed with diabetes type two are increasing worldwide. The years of life "lost" by virtue of living with sub-optimal quality of life (years lived with disability, or YLD).   Between 1990 and 2010, DM's all-age DALY rate increased by  30% worldwide.

 

Art adorns the streets of Havana.

This information is relevant to our field of psychiatry as patients with mental illness are more likely to be overweight, partly as a side effect of SSRIs, atypical antipsychotics, poor self care, that can not only increase the risk of diabetes, and the weight gain becomes a stubborn reality. Seriously mentally ill patients have frequent complications related to this serious disease- including foot ulcers and amputations. A more engaged primary care team as well a psychiatrist who regularly checks BMI and weight can advocate on their patients' behalf for better care.

 

Improved relations between Cuba and USA  can also open doors allowing exchange of newest medical inventions bettering possible health care for patients of both countries.

 

The team's five day trip ended with a idyllic exploration of the art scene of old Havana - amongst its many road side heavy weight steel modern art installations, that beckons passers by to pause in awe - to be in the moment, to engage. A gentle invitation to come back.

Janssen Announces U.S. FDA Approval of SPRAVATO™ (esketamine) CIII Nasal Spray for Adults with Treatment-Resistant Depression (TRD) Who Have Cycled Through Multiple Treatments Without Relief.  CLICK HERE for the full Press Release.   

* SPRAVATO™ uses the first new mechanism of action in decades to treat major depressive disorder.

* In short- and long-term clinical trials, those who received SPRAVATO™ and a newly initiated oral antidepressant achieved superior improvement in depression symptoms, and sustained improvement in their symptoms over time compared to adults who received a placebo and an oral antidepressant.

* To support responsible use of the medication while ensuring patient access, SPRAVATO™ will launch with a controlled distribution model, including a comprehensive Risk Evaluation and Mitigation Strategy.

Paid Advertisement - Premium Corporate Sponsor 2019-2020

The Arizona Opioid Prescriber Education program is a free online continuing medical education (CME) program for health care professionals that provides the latest information about Arizona's opioid laws and regulations, prescribing guidelines and treatment options for opioid use disorder. The education modules are accredited for all types of physicians, nurse practitioners, physician assistants and pharmacists and satisfy the license renewal three-hour CME requirements in Arizona law. Visit www.AzRxEd.org.