March-April 2017, Vol. 8, Issue 1
In This Issue


Premium Corporate Sponsor 2016-2017
Arizona Psychiatric Society
Newsletter Committee
Mona Amini, MD, MBA, FAPA, Editor-in-Chief

Brian Espinoza, MD, FAPA, CME Features

Robin Reesal, MD, FAPA,
Global Psychiatry Features

Aris Mosley, MD,
RFM Newsletter Representative
From the Newsletter Editor-in-Chief

Mona Amini, MD, MBA, FAPA

Dr. Marwah_ Teri_ and Dr. Amini at Afternoon Tea for Women_s Group
Dear Psychiatric Colleagues:

Spring Greetings to you all!

We have already had a busy year within the Society and its members, as will be shared in this edition of our Newsletter. The AZ Psychiatric Society Women's Group held a celebrated and rather fashionable event at the Phoenician for Afternoon Tea hosted by American Professional Agency, Inc., the APA-endorsed malpractice carrier. The Mental Health America Hall of Fame Ceremony honoring attorney Chick Arnold is highlighted, with members of the APS supporting this long-famed member of the behavioral health community.

In this edition, members will also meet Dr. Alicia Cowdrey, an early-career psychiatrist who leads MIHS' First Response Center treating first-episode psychosis. Dr. Noggle provides us with an update on the "Step Up Arizona" initiative and many other happenings in the behavioral health community, a report from APS Lobbyist Joseph F. Abate, a report from Area 7 Assembly, and other legislative updates including what psychiatrists may do to enforce parity (the participation of such is an even more important aspect of our careers as of late).

Our newest APA Life Members as well as the distinguished 50-year Members of the APA/APS are listed. Congratulations to the wonderful accomplishment of your fellow peers.  

Thanks to our regular Newsletter contributors, Dr. Espinoza for continuing medical education reports (in this edition, the famed Nevada Psychopharmacology Conference), and to Dr. Reesal for the global perspective on psychiatry (in this edition, on human trafficking, a very timely concern).  

For those interested in attending, our Annual Meeting is coming near on Saturday, May 6th, and includes a social reception on Friday evening and invitation to physician peer or RFM/Medical Student juried poster presentations on Saturday.   The registration link with complete agenda is provided below.

Warm Regards,


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

More Photos From the Women's Afternoon Tea at The Phoenician hosted by American Professional Agency, Inc.:

Arizona_s newest DF_ Dr. Marcelle Leet_ joined by Drs. Renate Fearonce and Shelley Uram

Dr. Amini addresses the attendeees at Afternoon Tea at The Phoenician

Gurjot Marwah, MD
Arizona Psychiatric Society, President

Colleagues, this is my final Newsletter address as President.  Our Summer Newsletter will transition to the new leadership, which I am confident will work diligently to continue the ongoing advocacy and behavioral health community efforts of the Society.  
Multi-disciplinary reps of IBHC of AZ

When I joined the Society, it was after several years of solo private practice, and  my membership in the Society has truly provided a meaningful way for me to connect with my fellow peers and to be a part of the mental health community of Arizona at large. I have  focused on reinforcing and broadening this engagement.  These efforts have been supported by the Council and our members. 

The Society organized the Integrated Care Training as a free event for our entire behavioral health community. Some of the other events I have had the fortune of attending as your President were: participation in the Mental Health of America Association of Associations meetings (and participating in public comment on pharmaceuticals and therapeutics, the able-bodied waiver, and the IMD waiver); being a principle member of the Interprofessional Behavioral Health Collaborative of Arizona (IBHCofAZ) (including the Arizona Psychological Association, Behavioral Analysts' Association, Arizona Chapter of the National Association of Social Workers, Association of School Counselors, and Marriage & Family Therapists); w ith Dr Alexander as its President, engaging with the Arizona Medical Association and participating in their Specialty Society Presidents' quarterly meetings; and supporting the Stepping Up Together initiatives. 

The highlight of this year for me has been formation of the Women's Group in Psychiatry (with great credit to Dr. Amini), and, I'm excited to report, the launching of a Men's Group in Psychiatry with its first event at Topgolf on April 30th.

The planning of the 2017 Annual Meeting has likewise been aimed at engagement at all levels, and I hope that you can attend and will also share the invitation with behavioral health providers from all categories. The more we work collaboratively, the better the outcomes for our patients and the better practice environments we create for ourselves as psychiatrists.

See you on May 6, 2017, and thank you for this opportunity to serve,

Gurjot Marwah, MD
President, Arizona Psychiatric Society, 2016-2017

PRMS_ Inc.

Saturday, May 6, 2017, Marriott at the Buttes Resort, Tempe (Poster Presenting Invitation for Physician Peer Posters and RFM and Medical Student Juried Posters) 

FREE to Arizona Psychiatric Society Members!
This full-day educational meeting targeted to psychiatrists and other behavioral health professionals, begins at 7 am with hosted continental breakfast, and 8 am for education. Speakers include Dr. Melanie S. Harned, from the University of Washington Behavioral Health & Therapy Clinics, with the Art and Science of Dialectical Behavioral Therapy and Integrating Treatment for PTSD onto DBT for Borderline Personality Disorder; Dr. David Shprecher on Pediatric Movement Disorders; hosted Lunch, APS Business Meeting and Awards; Legislative presentations from APS Lobbyist Joseph F. Abate, Esq. and on physician leadership and advocacy by Arizona Representative Heather Carter; Neurotherapeutics: TMS and ECT presented by Dr. Katharine N. Woods; and a two-part presentation by world-renown psychopharmacologist, Dr. Sheldon Preskorn, on The Organ of the Self: Neurobiology and Psychiatry (a two-part presentation, which, among other things, explains our current understanding of the brain and how its dysfunction leads to psychiatric illnesses and how treatment from psychotherapy to psychopharmacotherapy to other somatic interventions (e.g., deep brain stimulation) alone and in combination aids the restitution of function thus ameliorating these illnesses).  For a printable brochure, CLICK HERE.  

If you have any questions, or would like assistance in registering, e-mail teri@azmed.org or call 602-347-6903.


RFM and Medical Student Invitation. The Society invites all Arizona psychiatric residents or Arizona medical students to submit an abstract for consideration for a judged and scholarshipped poster presentation at APS 2017 Annual Meeting. Please review the APS Resident-Fellow and Medical Student Poster Guidelines for complete information regarding participation and prizes. 

Physician Invitation. The Society invites all Arizona psychiatric physicians to submit an abstract for consideration for a peer juried poster presentation at the APS 2017 Annual Meeting. Please review the APS Psychiatric Physician Peer Poster Guidelines for complete information regarding participation.

Visit the submission link at: https://www.surveymonkey.com/r/APSPosters2017 and provide the requested authorship information and submit your abstract of 3000 characters or less (including spaces). View the full Poster Presentation Invitation here


Marriott at The Buttes is offering a group rate of $149 plus tax while room availability lasts.  To book now, visit the reservation link at http://bit.ly/2mxHVNR or call the Marriott at The Buttes Group Rates Reservations (Sandy at 602.431.2392) 
Alicia Cowdrey_ MD

Alicia Cowdrey, MD
APS Early Career Psychiatrist
Psychiatrist/Medical Director
Pendgergast Community Center
10550 West Mariposa St, Suite 3
Phoenix, AZ 85037
Alicia Cowdrey, MD, hales from Cheyenne, Wyoming, where she lived until moving to Arizona in late elementary school, quickly developing a liking for everyday flip flops and sunshine versus snow shoveling and wind chill.  Alicia attended Horizon High School and faced the decision of moving away for college and found a love for the old pueblo, Tucson, AZ.  With an interest in both human behavior and science, Alicia attended the University of Arizona (Go Wildcats!) for undergrad, majoring in Psychology and Biology.  During undergrad, Alicia participated in various activities that would contribute to her career in health care, volunteering in hospice and HIV centers.

After completing undergrad, Alicia moved back to Phoenix and starting working in the mental health field, first working as a case manager for the Regional Behavioral Health Authority, then working her way up the ladder: supervising direct care clinic projects, working in program development to serve unmet system needs, and supervising the Maricopa County Assertive Community Treatment (ACT) teams.  This work helped Alicia solidify that working with folks experiencing everyday struggles was very valuable and rewarding work.  Realizing that she wanted more clinical interaction for her professional life, Alicia then returned to the University of Arizona for medical school, completing the first two years of study in Tucson, then returning to Phoenix for clinical rotations.  After completing all the required rotations, Alicia found that she still really enjoyed working in mental health, finding people's stories, histories, difficulties, and triumphs fascinating in their life journey.   

Alicia went to residency at Maricopa Integrated Health System (MIHS), due to the love of the acuity of the patient population, as well as the friendliness of the staff.  During her time at MIHS, she served as Chief Resident and enjoyed that role interfacing with both residents and attendings.  She did elective rotations specializing in various recovery principles and enjoyed learning about both patient and physician advocacy in the community.

After residency, she decided to take a well-deserved break and went on a three-month East Coast road trip, traveling from Maine to the Florida Keys.  After this sabbatical, Alicia started working with MIHS and DMG to start the First Episode Center, an innovative, evidenced-based, early intervention outpatient program for young adults having their first experience with psychosis.   She was drawn to this role due to her background in program development and ACT teams and due to the opportunity to be involved in expanding innovative outpatient programming in Maricopa County.  The First Episode Center operates as a Coordinated Specialty Care team, which focuses on improving mental health outcomes for youth.  The principles of shared decision-making, person centered care, strong involvement of physical health care, and the expectation of RECOVERY match nicely with Alicia's own psychiatry philosophies.  This work is fun and rewarding, supporting youth to get back on their life trajectory that they had before they had their first experience with psychosis.

In her non-work life, Alicia enjoys road trips and traveling, going to concerts and music festivals, cheering on the Arizona Wildcats, hiking, reading, and organizing random fun social gatherings for family and friends.

Honors Charles (Chick) Arnold, Esq.

On March 15, 2017, Mental Health America Arizona presents its first Mental Health Hall of Fame Bell to Charles (Chick) Arnold, Esq.  APS members, in the photographs below, attended to add their personal best wishes and Society congratulations to Mr. Arnold.  The Society could think of no one more deserving to be the first recipient of this award.  In the words of the host, " It was evident that night that Chick is a more than just a figure in our society, but an amazing individual admired and honored by all of us. No one more deserving to be the first members of MHA's Mental Health Hall of Fame."  For information on the advocacy and impacts of the outreach of Mental Health America Arizona, VISIT HERE.  

APS Members at MHA AZ Hall of Fame Event Honoring Chick Arnold_ Esq.


At the 2017 Annual Meeting, APS business meeting, the following nominated members will be voted upon to serve as the Arizona Psychiatric Society executive officers for 2017-2018:  
President:  Aaron Wilson, MD
President-Elect:  Mona Amini, MD
Vice President:  Don J. Fowls, MD
Treasurer:  Jasleen Chhatwal, MD
Secretary:  Gagandeep Singh, MD
Co Resident-Fellow Member Representatives:  Trace Cochran, MD, Maya Heck, MD, and Brandon Yates, MD
APA Assembly Representative:  Payam Sadr, MD*
APA Deputy Representative:  Mona Amini, MD (as President-Elect)**
Note: All Arizona positions are for one year.  Aaron Wilson, MD automatically moves from President-Elect to President.   Terms of office for the Arizona positions begin at the close of the Annual APA Meeting (May 2017) and end at the close of the 2018 Annual APA Meeting (May 2018).
*APA national positions are for two years.  The current APA Assembly Representative, Payam M. Sadr, MD, FAPA, is being nominated for a second two-year term, which will continue through the close of the 2019 Annual APA Meeting (May 2019). 
**Pursuant to the Bylaws of the Society, the President-Elect (Mona Amini, MD), will serve as the APA Deputy Assembly Representative for a one-year term that will end at the close of the 2018 Annual APA Meeting (May 2018).

Thanks to each of these members for their leadership and contributions! 
AZ Capitol

Joseph F. Abate, Esq.
APS Lobbyist
A summary of the Health Care Legislation relevant to psychiatry that has been introduced in each of the House or the Senate through March 31, 2017 in the Fifty-Third Legislature, Second Regular Session (2017), is available to view and/or print by CLICKING HERE.

Committee work has substantially concluded on the bills for this session.  It was a busy session with 1,056 bills dropped not including resolutions.  Preliminary work on the budget has commenced, but it is expected it will take some time to resolve various issues between the legislature and the Governor's Office.

For the house of medicine in general, a legislation of great concern this session continues to be SB1441, the surprise billing legislation, which recently passed the House Banking and Insurance Committee.  SB1441 would set up a dispute resolution process (settlement teleconference and arbitration) for patients facing surprise out-of-network bills over $1,000.  ArMA has led the effort, with other physician stakeholder groups, to try to find an appropriate solution that helps patient work through surprise bills while making sure that the solution created does not have unintended negative consequences to the health care system. The bill is very technical and complicated.  The stakeholders' goal is to create a process that helps patients resolve these bills and that encourages all the parties to reach an agreement prior to having to incur the costs and time expenses of arbitration. Stakeholder meetings will continue to try to work out the remaining issues with the bill.   
On the scope of practice front, SB1269, a bill arising from the pharmacist Sunrise Application, passed the House and has been signed by the Governor.  Stakeholder groups worked cooperatively with the pharmacists and in Sunrise hearings provided testimony regarding scope issues of initial concern regarding emergency refills and dispensing certain smoking cessation drugs.  

The CRNA scope of practice bill, SB1336, reached a compromise among the stakeholder groups that will keep the physician control of patients unchanged from current law, and still solve concerns raised by the CRNAs.  ArMA credits the contributions of House Health Chair Heather Carter who engineered the process and offered the critical concept that made the agreement possible.  With all parties in agreement, it is expected that SB1336 will move through the House voting process. 

Relating to mental health, HB2382, allowing a pharmaceutical manufacturer or its representative to engage in truthful promotion of an "off-label use" (defined) of a drug, biological product or device has made its way through the House and Senate and has been signed into law by Governor Ducey.  

HB2239 establishes procedures for the prosecuting agency and court to track incompetent defendants through the civil commitment process. Allows the county attorney to request an incompetent defendant be screened to determine if the defendant may be a sexually violent person under specified circumstances.  CLICK HERE to view the current Senate Fact Sheet and House Summary (including information on amendments to date). 

SB1236, dealing with reporting on psychotropic drug prescribing for foster children, passed House Judiciary & Public Safety with a physician stakeholder group amendment to resolve concerns about misinterpretation of the reported data by redacting physician identifiers.  SB1236 calls for a biennial report by the Department of Child Safety and AHCCCS that compares the prescription rate of "psychotropic medications" prescribed to foster children who receive services from AHCCCS with the prescription rate of psychotropic medications prescribed to non-foster children who receive AHCCCS services.  The bill was not opposed by AHCCCS.  SB1236 was replaced by a striker amendment dealing with statewide petition circulators; registration; committees and passed out of House Approp Committee as a striker by a vote 7-6. Therefore, the original content of SB1236 no longer is alive at this point.   The only way to return in this session would be added as a budget amendment.

By a close margin, SB1439 passed through the House and has been signed by the Governor.  SB1439 prohibits discriminating against a health care entity on the basis that the entity does not provide, assist in providing or facilitate in providing any health care item or service for the purpose of causing or assisting in causing the death of any individual.

As was communicated in member e-mails, the Society submitted a public comment letter (which you may read here) in response to the Governor's Office and AHCCCS invitation for public comment regarding provisions of past SB1092 (Modernizing Medicaid). Pursuant to the attached, the Society raises concern with the definition of "able-bodied"; the administrative burden and potential negative ramifications of work requirements, mandated copays, and income reporting; and lifetime limits for care, among other things.  In support of this message, Dr. Jasleen Chhatwal, current APS Secretary, was featured in a report on how those changes may affect Tucson families.  To see part of that interview, CLICK HERE.    

If you would like any additional information regarding the legislative session, please contact the APS Lobbyist, Joe Abate, at 602-380-8337.  If you are interested in being a part of the Legislative Committee of APS, chaired by Dr. Roland Segal, please contact teri@azmed.org. 
Arizona Medical Association Members Only Program

Arizona Psychiatric Society members who are also members of the Arizona Medical Association took advantange of a unique membership benefit to ArMA and participated in the Doctor of the Day program at the Arizona legislature.  Those members, photographed below, include:  Dr. L. Jay McIntyre, accompanied by his wife Carol, visit House Speaker Mesnard; Dr. Drew Williams with Rep. Salmon and Sen. Mendez; Dr. Gretchen Alexander (current President of ArMA and Past President of APS) with APS Lobbyist Mr. Joseph Abate; Dr. Brian Espinoza with Senator Brophy-McGee, Rep. Syms, and Rep. Butler, and Dr. Steven Streitfeld (background) with Dr. Randall Friese, Arizona Representative.  For more information about the Doctor of the Day Program and other benefits of membership in the Arizona Medical Association, CLICK HERE.    

Az Psych Members as Doctors of the Day at Arizona Legislature

Meadows Behavioral Healthcare
Topgolf on April 30, 2017 Sponsored by Meadows Behavioral Healthcare

CLICK HERE for a flyer to share, or CLICK TO REGISTER TODAY!

Topgolf Event Photo
APS Members and non-member psychiatric physicians alike are invited to the First Men's Group Event hosted by Meadows Behavioral Healthcare on Sunday, April 30, 2017 from 2 to 4 pm at Topgolf, Scottsdale.  Topgolf and food hosted.  Spots available on a first registered, first saved basis, so register to join in this fun event today!  
Salt Lake City, Utah

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

The Area 7 Assembly met March 4-5, 2017 in Salt Lake City, Utah, and Arizona was represented there by both Dr. Payam Sadr and Dr. Aaron Wilson.  Each of the District Branches in Area 7 reported on current structure, financial status, and legislative or other issues in their states.  District Branches have many issues in common, working to deliver the highest quality services possible to members within limited budgets.  Key issues discussed from the District Branch reports included scope of practice battles in Idaho, New Mexico, and Hawaii with psychologists seeking prescriptive authority.  Opioid use and treatment are priority issues in many states.  

There was a prolonged conversation regarding the potential effect of the recent Washington state Supreme Court decision that appears to significantly broaden the duty that psychiatrists and other mental health professionals in that state have to protect and warn potential victims of violence by a patient under their care.  In Volk v. De Meerleer, the Washington state Supreme Court expanded the so-called Tarasoff standard regarding a mental health professional's duty to protect and warn a third party of possible violence, asserting that the duty extends to any possible victim-even one that has not been specifically identified by the patient. If you missed the earlier Psych News article reporting on the same, CLICK HERE.  Although other states could conceivably adopt a similar standard, the ruling does not establish a legal precedent outside of Washington.  In the state of Washington, efforts are being made to address the potential implications through legislation.  For a comparison of duty to warn laws in the United States, CLICK HERE.  

There was discussion on the block grant that supports travel for the Area Assembly meetings.  With the travel distance in Area 7, it is a challenge to fund the required travel for the funded meetings.  The next meeting will occur in early August.  

Below are highlights of APA talking points from the Area Assembly meeting:

Recent Presidential Executive Orders
  • As we have seen with any Administration transition, there is a flurry of changes in rules, regulations and new executive orders. Some of these of changes will affect the mental health field at the federal and state levels, and could place an additional burden in your areas and your District Branches/State Associations. The APA Administration stands ready to assist when these situations arise. 
Repeal and Replace of the Affordable Care Act
  • Since early December, the Department of Government Relations (DGR) engaged key Congressional offices to educate Members of Congress and their staff on what has been gained under the ACA for individuals with mental illness, specifically in the areas of private insurance coverage, Medicaid expansion, parity expansion, mental illness as an Essential Health Benefit, and integrated care.
  • In January, APA President Maria Oquendo, M.D., Ph.D. and CEO/Medical Director Saul Levin, M.D., M.P.A. sent a letter to Congressional leadership requesting that any changes to the ACA do not undo the gains, which have been made over the past several years for individuals with mental illness. 
  • The APA Mental Health Registry, what we are calling PsychPRO, continues to meet our milestones and is ahead of schedule.
  • You will recall that the Registry to help participants meet Medicare quality reporting requirements for 2017 to avert a 4% financial penalty, and potentially achieve a bonus.
  • We have recruited multiple health systems and individual private practice psychiatrists for the Pilot Cohort Phase.  We hope to open the registry up to more members by the end of the year.
Mental Health Parity
In response to the White House task force's report on parity released last year, APA administration is conducting  webinars for DBs on network adequacy, and is f inalizing an audit tool for state agencies to use when evaluating parity compliance.  APA  will continue to work with the DBs in their advocacy for to request these reviews as well as provide updates on individual state developments.

Membership Update
  • At the end of 2016, total membership stood at 37,106, which is the highest level in 14 years.
  • APA membership increased by 1.7%, from 36,490 in 2015 to 37,106 in 2016.
New Member Resources

We have multiple NEW member resources mentioned in our update that include:
  • Policy:
    • A series of webinars, tool kits on Payment and Quality reform and how to meet the new Medicare requirements.  All of this can be found on the web site by searching payment reform.
    • A FAQ that helps members identify the best electronic health record (EHR) to meet their needs.  The FAQ is based on member questions most often received through the APA Helpline and is a living document, with new content added, as needed, to reflect members' questions. 
    • A new Mobile Apps Evaluation Tool. The Tool helps psychiatrists and other mental health professionals evaluate the efficacy and risks associated with "mHealth" technology, including popular mobile and online app. 
  • Education:
    • New information on line to help members understand the changes occurring within the American Board of Psychiatry and Neurology's (ABPN's) maintenance of certification (MOC) program. 
    • New Online Learning Formats: APA collaborated with the Association of Medicine and Psychiatry to develop APA's first Massive Open Online Course (MOOC) focusing on preventive medical care skills for psychiatrists.
    • New features in FOCUS include a section entitled The Applied Armamentarium, which focuses on changes in treatment; a column called the 21st Century Psychiatrist, which focuses on changes in systems of care; and a Year In Review highlighting the most promising breakthroughs in the psychiatric literature. Focus is currently seeking submissions within the new sections.
APA/APA Foundation Fellowships
  • The 2017-19 application cycle for all eight APA/APAF Fellowships closed on January 30, 2017.
  • The number of applications for funded fellowships received this year increased by 2% from last year, reflecting an upward trend since 2015 when new marketing strategies led to an initial 10% increase in applicants.
ICD-11 Proposed Transfer of Dementia Diagnoses
  • The World Health Organization (WHO) is proposing in its beta version of ICD-11, to transfer all of the diagnoses for Dementia from the Mental or Behavioural Disorder chapter into the chapter on Diseases of the Nervous System.
  • The potential absence of these diagnoses in the Mental or Behavioural Disorder chapter will preclude mental health professionals from providing necessary mental health services to patients with Dementia in the U.S. and other countries.
  • Dr. Oquendo and Dr. Levin submitted a letter to WHO to formally protest the proposed changes.
  • The APA letter strongly requested the reintegration of Dementia into the ICD-11 Mental and Behavioural Disorders chapter.
  • Other national and international organizations submitted or are preparing letters to send to WHO to protest the proposed changes for Dementia diagnoses in ICD-11.
2017 Annual Meeting Highlights  
  • Dr. Oquendo's theme for the meeting, "Prevention Through Partnerships." 
  • With over 2,000 submissions the program includes 440 programs and 30 in-depth courses and four master courses. 
  • Working with the U.S. Navy, the APA will also offer an EduTour to the Naval Medical Center San Diego Base Balboa. EduTour participants will learn about the delivery of medicine at sea aboard the USNS ship, Mercy, which is the lead ship of her class of hospital ships in the U.S. Navy. 
  • ABC's 20/20 co-anchor Elizabeth Vargas has been confirmed as our Convocation speaker.  Vargas will be interviewed by NIDA Director Nora Volkow, M.D., about her struggles with anxiety and alcohol abuse. 
    • Susannah Cahalan, author of Brain on Fire: My Month of Madness, will be speaking at the opening session.
    • The Jacob K. Javits Public Service Award will be presented to Representative Tim Murphy, of Pennsylvania's 18th District, for his exceptional leadership in bringing comprehensive mental health reform to fruition.
Poster Promoting Parity Rights
Poster Promoting Parity Rights
What Psychiatrists Can Do to Help Enforce Parity
Patients Need Your Help to Enforce Mental Health Parity

With all the recent discussion of the future of the Affordable Care Act (ACA), members have asked about the impact of the ACA's destiny on the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA is a separate statute that applies to large group employer plans (+50 people), Medicaid managed care arrangements and nonfederal government plans that do not opt out. The ACA expanded MHPAEA to Medicaid expansion plans, Exchange Plans and to the individual and small group markets. Right now, MHPAEA impacts almost all insurance products on the market, and your patients need your help in dealing with possible parity issues and ensuring access to care. What can you do?

1. Work with your patients to recognize potential parity violations and complain when they experience one.
One of the most common things APA has heard from regulatory authorities is that violations cannot exist because no one is complaining! Twenty states have been granted money by the federal government to enforce parity in the state. Regulators need to hear from you to know where to look for problems. You must not be silent.

Here are some potential parity violations: 

A. Pre-authorization
including blanket preauthorization requirements for all mental health or substance use disorder (MH/SUD) services, treatment facility preauthorization requirements not applied to medical/surgical services, or more stringent medical necessity review or prescription drug preauthorization requirements than those applied to medical/surgical services; 

B. Fail-first protocols, requiring an individual to fail to achieve progress with a less intensive form of treatment before a more intensive form is covered;

C. Probability of improvement requirements, for example, offering coverage of continuing treatment only if improvement is demonstrated or probable;

D. Written treatment plans, requiring treatment plans completed by specified professionals, within a certain time, or on a regular basis where similar requirements are not applied equally to medical/surgical coverage;

E. Other limits or exclusions, including:

* Excluding chemical dependency services in event of noncompliance,
* Excluding coverage for residential treatment,
* Geographical limitations on MH/SUD services not imposed on medical and surgical services, or
* Facility licensure requirements not imposed on medical/surgical facilities. 

Each of these is explained in detail in this document.   If you or your patients experience these issues, go to this consumer portal, and complain.  https://www.hhs.gov/mental-health-and-addiction-insurance-help  Federal authorities have assured us that there are benefits experts available to help with the problem and/or steer people to the right place. 

2. Help your patients ask for documents from their insurance plan when their care is denied.
The Substance Abuse and Mental Health Services Administration (SAMSHA) recently issued a new consumer rights publication that specifies what documents patients are entitled to get from their plans, if they ask, when their MH/SUD care is denied. It is important to get further information from the plans and SAMSHA has made clear that the patient is entitled to information both on the MH/SUD side of the plan and from the medical/surgical side of the plan to determine if MH/SUD is treated differently. These documents include: the plan's medical necessity criteria, utilization review standards, and its analyses performed to verify whether the plan complies with MHPAEA. We suspect that many plans do not do actually do the required analysis under MHPAEA and therefore cannot comply. SAMHSA's Consumer Rights publication provides for discovery from the health plan of a wealth of information and patients need to take advantage of it. See, SAMHSA's publication here: http://store.samhsa.gov/shin/content/SMA16-4992/SMA16-4992.pdf . If you need assistance once a document request is made and the documents are produced or not produced, please contact Maureen Bailey at mbailey@psych.org.

3. Do not substitute a consumer complaint to enforcement authorities for an appeal.
Patient have only a limited amount of time to appeal a denial of a claim. Filing a complaint with a regulatory agency is not a substitute for an appeal. Help your patient appeal denials and include in the appeal a claim that the action may violates MHPAEA. Also include in the appeal a request for the documents in the SAMSHA publication above. Many denials are reversed on appeal, particularly when the appeal advances to the external stage and an independent third party. Don't give up, when the patient's claim is not appealed, the plan wins.

4. Post the APA's parity rights poster in your office.
This poster clearly and simply explains the parity law and the steps to take when a violation is suspected. Share the poster with your colleagues. (Poster includes a Spanish translation.)  
5. Tell APA about your experiences.
APA is in regular contact with state and federal authorities tasked with enforcing the parity laws and they need feedback about patients' experiences getting MH/SUD care which may implicate the parity laws. If APA is able to collect sufficient data, APA can better relay to the authorities what is working and not working with parity enforcement. Contact mbailey@psych.org.
For patients, parity means reasonable access to care. For psychiatrists, it means the ability to practice medicine without unnecessary interference so that you can spend your time in patient care rather than intentional hurdles to block care. Psychiatrists have made substantial gains in making parity a reality, but it requires vigilance and your participation. Keep up the good work!

Dr. Matthew Goldenberg
Matthew Goldenberg, DO
Southern California Psychiatric Society, Newsletter Editor
Psychiatrist, Addiction Treatment Specialist
@SoCalPsychSoc or @docgoldenberg 

Recently catching up with Dr. Matthew Goldenberg, a member of the Arizona Psychiatric Society during his residency at Banner UMC Phoenix, and Co-RFM Representative at that time, he shared with us the news that he has continued his work in leadership and advocacy.  With permission, we share here a link to the January 2017 newsletter of the Southern California Psychiatric Society, which includes a Letter from the Editor (Dr. Goldenberg) beginning on page 3, A Call to Action to Stand Up For Parity.  We invite you to enjoy this article (and others) from our partner District Branch and fellow APA member.  Other issues of the SoCalPsych Newsletter are posted at http://socalpsych.org/newsletter.html 

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

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

The Arizona Mental Health and Criminal Justice Coalition wishes to thank Maricopa Integrated Health Services and Sherrie Fraley for organizing and providing for its January strategic planning meeting.
The Stepping Up(1) message is spreading and appears to be achieving the "movement" status we all have hoped for, reaching beyond a fleeting moment. As Yale law professor James Forman recently wrote in the New York Times(2), the problem of over incarceration occurred incrementally and "was built locally" and will be solved in the same manner.  As of February 2017, 340 Counties, representing 35% of the country's population have signed a Proclamation "to step up" and reduce incarceration of seriously mentally ill people in county jails. 

Stepping Up Around the State:

In Arizona, 13 Counties have signed up and Apache County indicates doing so within the next month. That leaves one County! NAMI Arizona's Annual Meeting in January 2017 featured Andrew Sperling, NAMI National Director of Legislative Advocacy, as well as local leadership including Tom Betlach, AHCCCS Director, MMIC CEO Eddie Broadway and other RBHA leaders who spoke to their strong Stepping Up commitment to provide necessary community based clinical and social support services for the justice involved population.  Most recently, Mary Lou Brncik, Arizona Mental Health and Criminal Justice Coalition leader, provided additional Stepping Up training to the Cochise County Re-Entry Council.

Upcoming events: 
David_s Hope AZ
Davids Hope AZ

Pima County is bringing Judge Steven Leifman, a chief architect for Stepping Up, to Arizona for its Decriminalizing Mental Illness Conference, May 16 and 17 in Tucson(3).  

Save the Date for the Second Annual Step Up AZ 2017 Mental Health Criminal Justice Summit on Aug 24-25  which will be held at the Embassy Suites, Tucson ( info@davidshopeaz.org ).  (Awards Dinner on August 24 with sign-in at 3:45 pm and dinner at 4:30 pm, and Summit on August 25.)  CLICK HERE for a Save the Date flyer to share with peers.  

NAMI Valley of the Sun "Breaking the Silence" Fundraising Breakfast, April 27, 7:30 am.  CLICK HERE to a flyer to share, or for more information contact the NAMI Valley of the Sun Development Committee Chair, Paige Rogers, at 602-538-6021 or P.Rogers@namivalleyofthesun.org.   
From APA President Renee Binder, MD
In the news: February 2017 Journal of American Medical Association, featured an article by  Renee Binder, MD and Matthew E. Hirschtritt, MD(4) citing four steps necessary to reduce the harmful revolving door cycle for mentally ill individuals returning to jail and prison: 
  • prevent justice involvement by effective intervention in the community (Crisis Intervention Trained first responders, crisis mobile teams, homelessness outreach)
  • promote engagement with treatment in the community and diversion to community based treatment which includes assisting individuals to adhere to court appearances
  • provide compassionate, comprehensive psychiatric care in correctional settings
  • prepare individuals leaving custody for effective community reintegration and develop effective community based services for justice involved mentally ill individuals. 
Stepping Up actions across the state that address these key points:
Arizona has embraced the importance of early, pre-arrest community intervention highlighted in the GAINS Center updated Sequential Intercept Model which added "Intercept 0" https://www.prainc.com/wp-content/uploads/2016/11/Intercept-0-Infographic-2.pdf with the stated goal "to align systems and services and connect individual in need with treatment before a behavioral health crisis begins or at the earliest possible stage of system interaction." Each year an increased number of local policing agencies and other first responders are receiving CIT training as a crucial, cost effective step. In order to gauge effectiveness of this work, Phoenix Mayor Greg Stanton's Commission on Disability Issues (MCDI) just released a report(5), p repared by the Cross-Disability Crisis Intervention Workgroup, based on extensive surveying police officers as well as community members with mental health needs. The following are some key findings:  
Most respondents with mental health issues reported at least one interaction with police officers in the last five years.
  • Half of those respondents reported being helped by the involved officers.
  • 45 % stated that the police made it worse.
  • Police officers reported feeling overwhelmed in such instances and identify the need for more mobile crisis teams and treatment availability.
  • Over 77% of Phoenix police respondents indicate having had some training in this areas.
We commend the City of Phoenix for its commitment to measure its work, producing this important research, and to continue its commitment of maintaining at least a 20% trained CIT force.
Binder and Hirschtritt point out that the lifetime arrest rate for homeless individuals with serious mental illness ranges from 62.9% to 90%.  Earlier research conducted with a New York FUSE project indicated that most of the chronically homeless individuals they served had an episode of incarceration preceding losing housing.  Finally, we know that in the Maricopa County jails, 1 in 4 people report some level of homelessness when they enter the jail.  Accordingly, the Maricopa Association of Governments Regional Continuum of Care(6) working to end homelessness, its various committees, and associated housing providers and agencies are exploring ways to effectively address justice involved individuals, many of whom also have mental illness and/or substance use disorders.
County jails such as Yavapai, Pima and Maricopa are strengthening relationships with the RBHA community based behavioral health providers such as Community Bridges, Southwest Behavioral Health, Terros, Valle del Sol, and Partners in Recovery who are developing programs and staff dedicated to reach in activities to coordinate care for individuals transitioning from jail to community.  Experience has shown us that specialized training for agency staff and approaches geared toward the justice involved population are essential to promote successful re-entry and to reduce recidivism.  While medications are vital to recovery for many individuals, more immediate needs such as transportation upon leaving jail, having a safe place to land and a person who conveys respect, hope and navigation for the first 24 hours upon release is preeminent.  Ongoing community based treatment must address those "criminogenic" risk factors that are contributing to people getting stuck in the revolving jail door, risk factors related to antisocial thinking, behavior and associates that are not typical treatment considerations for individuals with no or minimal justice involvement.
Mercy Maricopa Integrated Health Care and Terros are leading an exciting effort in the Phoenix area to promote more consistent evidence based practices across agencies that are providing services for the justice involved population.  Twenty community agency programs have voluntarily completed the "Risk-Need-Responsivity Simulation Tool"(7)  ( https://www.gmuace.org/research_rnr.html), a web based "decision support tool" developed  by George Mason University. The results show programs their areas of strength and weakness for further program improvement.  The ultimate goal is to have enough data and agency participation to complete a jurisdictional Risk-Need-Responsivity Assessment to identify gaps and promote the community service system that Binder and Hirschtritt are advocating. 
Stepping Up leaders across the country also agree that jails must provide effective psychiatric services addressing the complex needs of the mentally ill and substance misusing population.  This has been the leading topic at the National Institute of Corrections large jail conference for the past few years as jails, not built to be mental health facilities, work to manage and provide such care.  Increasingly, jail health staff must operate with an integrated health care model. Maricopa County Correctional Health Services, as an example, provides 24 hour/7 day a week medical providers at our jail intake, many of whom are now certified in psychiatry.  A multidisciplinary team of nurses, counselors, social workers and providers identify acute and chronic health needs from suicide risk to withdrawal symptoms to elevated risk due to diabetes or hypertension such that these individuals receive immediate stabilization and ongoing care for their in custody duration.  While county jails across the state are working on early diversion and release programs (such as Maricopa County's diversion to Southwest Behavioral Health's program for low risk SMI individuals at Initial Appearance and Yavapai's Early Disposition Court), inevitably there are still seriously mentally ill individuals in custody who need a higher level of care.  Jails must have the ability to transfer those patients to a hospital environment.  Arizona, as other states across the U.S., struggles with psychiatric hospital bed availability. However, Maricopa Integrated Health Services accepts jail patients at Desert Vista for brief hospital stays associated with the court ordered evaluation and treatment process.  These brief hospitalizations foster increased treatment engagement and allow for patients to return to jail for continuing care.
Ultimately, regardless of the quality of care while incarcerated, connection to treatment when returning to the community is paramount.  The AHCCCS Justice Transition Initiative, requiring health plans to "reach in" to members with chronic medical and behavioral health conditions for coordination of care, is an excellent example of a unique statewide Stepping Up effort.  In the first quarter of this AHCCCS mandate (October-December 2016), Maricopa County received 306 requests for care coordination.  There have been a total across the state of 888 coordinated reach in services.  And this is just the beginning.
Finally, Yavapai Re-Entry Project(8) just hosted their "Second Chance for Life" conference 3/23/17.  According to MCSO Lt. Michael Kreutz who attended, they shared that their program has helped 200 Yavapai County residents returning for jail and prison. They have used an innovative approach, incorporating volunteers as coaches following individuals for up to a year. They estimate a cost of $250 per person.  In place for 5 years, they are showing a record recidivism rate of 6%.  An important lesson for all of us in this Stepping Up effort is recognizing that each region may have different approaches within the Stepping Up framework and that we must use resources at hand to meet the needs of communities. 
Here's the great news:  There are so many innovative and effective local, incremental efforts, too many to report in one article.  We know that sustainable change is best made this way, from the ground up, by contagious efforts and activity.  Stepping Up is catching on and taking hold!
Resources and References

4. Renee L. Binder, MD, Interrupting the Mental Illness-Incarceration-Recidivism Cycle,  Article Information,  JAMA. 2017;317(7):695-696. doi:10.1001/jama.2016.20992
8.  For more contact: info@YavapaiReentryProject.org or (928) 708-0100


UofACOM Dept. of Psychiatry NAMIWalks Southern AZ Team 2017
Thanks to Co-RFM Representative Dr. Brandon Yates for planning the RFM Mixer in Tucson on April 1, 2017, which was a brunch immediately following the NAMIWalks Southern Arizona fundraising event.  What a fun way to celebrate the walkers and their contribution of time in walking to support the valuable services and outreach of NAMI Southern Arizona! The Department of Psychiatry team was a top team fundraiser!  

RFM Tucson Mixer 2017

We hope all RFMs will plan to attend the next RFM Mixer, at the conclusion of the educational day on Saturday, May 6, 2017, at The Buttes Resort.  If you have questions about the RFM Mixer (open to all Arizona psychiatric residents), please contact Teri (teri@azmed.org or 602-347-6903) or speak with the RFM Representative from your residency program (Dr. Heck, MIHS; Dr. Shao or Dr. Cochran, Banner UMC Phoenix; or Dr. Yates, UACOM Tucson).  Join us at the Annual Meeting (free to Residents, whether members or not), and also read the information above regarding the invitation to poster present.  

Celebrating Excellence_ Congratulations
The following members of the Arizona Psychiatric Society are being recognized by the APA for reaching the following Life membership status as of January 2017:

Mary Catherine Nowlin DO DLFAPA
Stephen Paul Herman MD LFAPA
Howard Keith Mason MD LFAPA
Narendra Chauhan MD LFAPA
Shelley Jacquelyn Doumani-Semino MD LFAPA
Balbir C. Sharma  MD LAPA
Of special note, we recognize the following members who achieved the pinnacle of 50-Year Members in the APA as of January 2017:

J oseph D. Bloom MD DLFAPA
Ronald V. Nazareth MD LFAPA
Robert E. Cottor MD LAPA
These members will be acknowledged in the Convocation at the 2017 APA Annual Meeting and recognized in the Program for the APS 2017 Annual Meeting as well.

Congratulations to these members of the Arizona Psychiatric Society on their distinguished careers, and thanks for their continued support and membership in the Arizona Psychiatric Society and the American Psychiatric Association.  
Choice is Beneficial to Patients, Healthcare Systems, and Society

As a result of rising U.S. healthcare costs, and in a time of increased fiscal tightening, stakeholders across the healthcare system, from providers to insurers, continue to seek ways to reduce spending.  Two areas that insurers have identified are drug formularies and formulary restrictions, including prior authorization and step therapy. While these restrictions may reduce medication costs in the short term, they have also been shown to possibly contribute to worse patient outcomes and higher overall healthcare systems spending. This is particularly true when it comes to treatment for individuals with serious mental illness (SMI) such as schizophrenia, schizoaffective disorder and bipolar I disorder.   CLICK HERE for printable Background Issue Brief on Restricted Access to Medication and Unintended Negative Consequences in Patient Care and Health Systems.   


Each month APA makes available a free CME course exclusive to members only through its Learning Center. April's course is Managing the Side Effects of Psychotropic Medications.  Featuring Joseph F. Goldberg, M.D. from the Icahn School of Medicine at Mount Sinai, this course provides viewers with an overview of systematic assessment approaches to suspected adverse drug effects.  CLICK HERE for more information.

2017 GRAND ROUNDS FOR THE DEPARTMENT OF PSYCHIATRY BANNER-UNIVERSITY MEDICAL CENTER EDUCATION AMPHITHEATRE.  Held on scheduled Fridays from Noon to 1 pm, the April Grand Rounds schedule includes chronic pain, opioid use, and toxidrome presentations.  For the full Schedule, CLICK HERE. No Grand Rounds on April 17, 2017.    

Southwest Psychoanalytic Society Relational Psychodynamic Therapy:  "Working with Tensions in Theoretical and Clinical Realms" Presented by David Levit, PhD, ABPP, Saturday, April 22, 2017, 9:00 am to 3:15 pm at Hacienda Del Sol Guest Ranch Resort, Tucson, Arizona.   CLICK HERE for the flyer; visit http://swpsychoanalytic.org for additional information or other upcoming seminars.

http___www.mhaarizona.org_events.htmlThe 2017 Mental Health America of Arizona Seeds Conference - Navigating the Hurdles: B4Stage4 is going to be on May 24th, 2017 at Glendale Community College!  Join together with individuals and family members living with mental illness, health care providers, and other mental health partners in public safety, education and faith communities, in discussing the early detection and prevention of mental illness.  Former NFL great, Mark McMillian, is the featured keynote presenter. Nicknamed "Mighty Mouse," McMillian started off working in the mental health field before completing an eight year career in the NFL. Visit http://www.mhaarizona.org/events.html for information on sponsorship, updates on breakout sessions and additional speakers, and registration information.  CLICK HERE TO REGISTER today.

NEUROSCIENCE OF ENDURING CHANGE:  Applications to Psychotherapy - September 15-16, 2017 - Tucson, Arizona

Sponsored by the Departments of Psychology and Psychiatry

The modern era of psychotherapy began over a century ago guided by the assumption that psychological treatments were mediated by changes in the brain. Although we are far from fully understanding the neural basis of enduring change in psychotherapy, recent developments in neuroscience provide a foundation for advancing knowledge in this area.
The purposes of this two-day conference for researchers and clinicians are: (1) to define a research agenda for the neuroscience of enduring change, (2) acquaint researchers and clinicians with recent basic research findings and their clinical implications, and (3) discuss the mechanisms of enduring change in psychotherapy from the perspective of the major psychotherapy modalities.  

  • Early Registration (before 10pm, August 1st) - $275 
  • Registration (after 10pm, August 1st) - $350
  • Reduced Rate for Graduate Students, Postdocs and Residents - $50
The 22nd Nevada Psychiatric Association National Psychopharmacology Update:  February 16-18, 2017

Brian Espinoza, MD, FAPA
Interventional Psychiatry
APS CME Contributing Editor

This was my tenth year in attendance, and this conference continues to grow, and remains the largest Psychopharmacology Conference in the country. 

Some highlights from notes taken include:

Beyond Dopamine: Evolving Treatments of Schizophrenia
Emphasis was on preventing the "second episode"; a study showed a 600% increased relapse rate on oral Risperidone vs. Riserdal Consta; use of Long Acting Injectables during the first episode was strongly suggested.
Approximately 4% of patients ever receive Clozapine, while it is estimated that 20-25% of patients are Treatment Resistant.
There is emerging evidence suggesting Atypicals are neurogenic, while there are about 30 in vitro and animal studies showing Haldol is neurotoxic.

Bipolar Disorder: Clinical Complexities and Controversies
Bipolar patients have 2-3 times the risk of obesity, hypertension, dyslipidemia and diabe-tes; is there a pleitropic gene common to these disorders?
There is a higher association of psoriasis and Bipolar Disorder.
8 studies show Clozapine useful in Bipolar Depression.

Psychotropic Drugs in Development: Hope on the Horizon?
Jansenn Phase 3 Trials of IntraNasal S-Ketamine are in process: Phase 2 had good re-sults; appears to have a rapid anti-suicidal effect.
Lanicemine is another NMDA antagonist; 1 positive study and 1 negative study so far.
SAGE-547 is an allosteric neurosteriod modulator of GABA-A; 1 IV study shows rapid improvement lasting up 30 days.
A current study at Duke is targeting anhedonia with a Kappa Opioid agonist.

ADHD in Adults: Update on the Diagnosis, Impact and Treatment of a Life Cycle Disorder
50-65 % of young ADHD patients still have residual symptoms or the full syndrome into adulthood.
A 2016 Swedish National Registry study suggested that Bipolar patients can be safely treated with a Stimulant after Mood Stabilizers are established.
There is a significantly lower rate of drug diversion with the Long-Acting Stumulant prepa-rations.

Treatment of Depression in Children and Adolescents
MDD is the 3rd leading cause of death in adolescents (MVAs #1 & HIV/AIDS #2)
A 2016 study following children over an 11 year period showed cortical gray matter vol-ume loss and thinning on serial MRIs.
An Adolescent study showed a 53% rate of full recurrence, 80% developed non-mood disorder comorbidities (anxiety, substance abuse, eating disorders); only 25% achieved depression free status.
2 studies of Duloxetine failed; Duloxetine, Fluoxetine AND placebo all improved.
A Ketamine trial is in the planning stages.
ECT; retrospective studies only; looking at 51 adolescent case, 77% improved.
rTMS; 2 Open Label studies with small numbers; 33% improved.

Diagnosing and Treating Schizophrenia in Adolescents
Latuda is the new kid on the block receiving FDA approval for Adolescent Schizophrenia in February of this year.
The Speaker recommended Clozapine only after trying all 5 FDA approved treatments for Adolescent. Schizophrenia; a stark contrast to Adult Schizophrenia expert recommendations on Clozapine; my question on this dichotomy was screened out by the Moderator.

Novel Uses of Atypical Antipsychotics
Risperidone and Olanzapine decrease CAPS scores (Clinician Administered PTSD Scale).
Atypicals in Dementia-Related Psychosis; several systematic reviews show "modest" benefit in behavioral symptoms of dementia.
Stuttering: Risperidone, Olanzapine and Asenapine all have shown benefit; Ecopipan, a D-1 antagonist is currently in study.
Autism: Risperidone and Aripiprazole have been shown to be effective in irritable and ag-gressive behavior.

The Neurobiology and Treatment of PTSD: Problems and Promises
70% of cases improve on their own; the speaker wondered if the Mental Health First Re-sponders to 911, may have done more harm then good; i.e. iatrogenic exacerbation/prolongation of PTSD.
A recently published VA study compared Group vs. Individual CBT for PTSD; Individual CBT was better.
A VA retro-analysis looked at the use of ECT in Veterans with comorbid MDD & PTSD; the findings were that both MDD & PTSD improved along with robust decreases in suicidality.

Physician Suicide: What you can do to save a life
A poignant and touching topic; we lose a doctor a day by suicide.
One study is showing that web-based CBT is reducing Suicidal Ideation in Medical Interns.
Burnout strategies are being deployed by some Residency Programs.
The speaker emphasized that all of us come back home and "do something" and gave a list of ideas.

Update on Medication Assisted Treatment for Substance Use Disorders
TOBACCO; 42% of mentally ill smoke; Brief verbal interventions by Physicians, as little as 3 minutes, increase quit rates; Nicotine Nasal Spray has the highest potential for dependence and 20% will use longer than the initial treatment course; 20% of e-cigarette smokers will become regular e-cigarette smokers, thus the FDA does not recognize this modality.
ALCOHOL; Gabapentin at 1800 mg/day showed decreased craving and increased rates of abstinence; Topiramate at 300 mg/day showed decreases in amount consumed; Disulfiram best used in legal system or employment mandated; Naltrexone decreases consumption and cravings; it was suggested to use Acamprosate if Naltrexone ineffective or Disulfiram not viable.
COCAINE; Succinylnorcocaine, an antagonist vaccine, failed preliminary trials.
MARIJUANA; N-Acetylcysteine; 2 trials, 1 with mixed results, 1 negative; Cannabinoid agonists are under study.

Assessment and Treatment of Opioid Use Disorder
Opioids are the most prescribed class of medications in the U.S.
Naltrexone appears to be effective in those motivated to discontinue use, and, have an employment or safety mandate (e.g. Health Professionals), and/or those that do not want agonist therapy.
Buprenorphine, a mu opioid receptor partial agonist, appears to promote long-term en-gagement in long-term opioid treatment programs up to 1 year.

Next Report: The 27th Annual International Society for ECT & Neurostimulation (held in conjunction with the Annual APA meeting); May 21, 2017

Dr. Espinoza is an APS Member and an Interventional Psychiatrist specializing in 
Electroconvulsive Therapy (ECT), IV Ketamine for Depression, Genetic Testing, Enhanced Medication Management, and Pharmaceutical Research.  

Haven Senior Horizons has a unique opportunity for a Psychiatrist to join our 45 bed hospital and join a team that is growing. We will be opening another 12 bed unit in late summer 2017.
Position duties include but are not limited to; admission evaluations, daily patient rounding of assigned patients, and coordination of care and treatment planning with the inter-disciplinary team.
There is opportunity to work as an employed physician with salary and full benefits OR if preferred compensation can be structured as a fee for service independent contractor.   Please contact Human Resources at 623.236.2023 for more information. 


March 2017

Robin T. Reesal MD
APS Member
Private Practice in Liberia, Africa

The face of human trafficking or trafficking in people is not only unflattering but shows a darker side of human nature. The disempowered and disenfranchised women, children and men around the world are at greatest risk. Trafficking in human beings shows what can happen, when the rule of law is absent or not enforced. According to the U.S. State Department 2016 Trafficking in Persons Report, trading human being is a 150 billion dollar industry.(1)

The following quote from the Trafficking in Persons Report offers further insights into this global problem.(1)

Jessica a sex trafficking survivor said, "At first, I thought he was my boyfriend. Then he convinced me to have sex with strangers to make money. He was my pimp. I was 15 years old. I was being advertised on the Internet and sold for sex to support my 'boyfriend'."
In South Asia, some traffickers maim children before subjecting them to forced begging to increase the children's profits.(1)

Martin, a former child soldier in the Democratic Republic of the Congo summarized his experiences. "We slept on the ground. We had to loot villages to eat. We were drugged to remain obedient. We were forced to kill. When I was in the armed group, I committed violence and crimes. I lost my childhood, my friends, and my mother."(1)

Recently, one day while walking on the main road in Monrovia, Liberia I witnessed the following scene. A blind African older man dressed in aging and worn clothes stood on the side of the road with a cane in his right hand. His left hand was around a boy of four or five years old. The young boy was crying. He was being forced to beg for money. 

What is trafficking in persons or human trafficking? 

The WHO document "Understanding and addressing violence against women - Human trafficking" simplifies the United Nations definition of trafficking into three parts. The first part consists of the act of recruiting, transporting, transferring, harbouring or receiving a person; the second part refers to the means used, such as coercion, deception or abuse of vulnerability; and the final component is the recruitment and deception is for the purpose of exploitation.(2, 3) The terms trafficking in person and human trafficking are synonymous.

Where are people trafficked? 

According to the United Nations Office of Drugs and Crime (UNODC), people are trafficked across continents, with neighboring countries and within countries. Between 2012 and 2014, the UNODC/WHO 2016 Global Report on Trafficking in Persons found more than 500 different trafficking "flows" around the world. (4) Human trafficking victims from 137 different countries have been identified as reaching the shores of Western Europe and Southern Europe. Trafficking is believed to be higher among migrants because of their level of desperation and lack of legal protection. The rate of domestic trafficking has been going up between 2012 and 2014. About 40 % of trafficking is domestic. 

Who is involved in human trafficking? 

Although most victims of trafficking are women and children, the rate of men being trafficked is increasing. Globally, in 2014, about 51% of people being trafficked were women, 28% were children (20% girls and 8 % boys) and 21 % were men.(4) 

The majority of traffickers are men but women are involved. Traffickers often come from the same region, speak the same language and share the same culture. Traffickers can be in the destination country or the home country. Because trust is an important factor, women are used to gain the trust of other women or girls who can be trafficked. Family ties can also be used to gain trust and traffic people. (4) Organized crime is another group that is actively involved in human trafficking. 

Why are people being trafficked? 

When people think of trafficking they may think of the traditional description of a female from a resource poor country being brought to a resource rich country for sexual exploitation. While this remains a prominent problem, the picture is changing. 

There is a trend towards more people being trafficked for forced labor. Between 2012 and 2014, about 40 % of people were trafficked for forced labor with men making up about 6 in 10 of these victims.(4) Other reasons for trafficking include to recruited child soldiers in conflict areas. Some are trafficked for organ transplantation. Others are taken for begging and some for forced marriages,(4) some children are taken to be sold. My mother told me years ago that as a child someone from a developed country tried to buy me while she was waiting for a flight at an Airport in the Caribbean. My life was in the hands of my parents. Sadly, while the incident is a family memory other children may have seen their parents for the last time at that airport. Child trafficking is the predominant form of trafficking in the Caribbean and Central America.(4)

Is there greater risk of human trafficking in times of Crisis and Conflict areas? 

Yes, and this has become a newly recognized problem. This knowledge has resulted in changes to crisis management around the world. The International Organization for Migration has played a pivotal role in identifying and addressing this issue.(5)

The setting is right for increased human trafficking in conflict areas or areas after a major man made or natural disaster. There is lawlessness and institutions are disabled. The social structure is broken so people are financially desperate. Internally displaced people are desperate and vulnerable. Response workers may be making sexual demands. There is a general lack of protection and available solutions to hunger and financial needs. Cultural factors in male dominated areas can lead to more forced marriages. Discrimination on class, socioeconomic status, race and cultural background can lead to a hazardous environment. The International Organization for Migration's 2015 report provides a description of case studies in such places as Libya, Iraq, Yemen and Nepal.(5)

What is being done to help?
Yes, in 2000 the United Nations pushed for an international treaty, "Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime."(2) The World Health Organization has also started to address the issue of human trafficking head on with its 17 Sustainable Development Goals developed in 2015. Item 16.2 of the SDG's calls for the "end of abuse, exploitation, trafficking and all forms of violence against and torture of children." (4) Item 5.2 promotes the ending of "...all form of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation,"(4) SDG item 8.7 promotes," taking immediate and effective measures to eradicate forced labour, end modern slavery and human trafficking and secure the prohibition and elimination of the worst forms of child labour, including recruitment and use of child soldiers, and by 2025 end child labour in all its forms."(4) One hundred and fifty countries signed the United Nations agreement for the SDG's.(2)

The United States Government has produced the Trafficking in Persons Report 2016, which highlights the extent of the problem in countries around the world.(1)

I will end with the following quote from former President Barak Obama "Across the globe, including right here at home, millions of men, women, and children are victims of human trafficking and modern-day slavery. We remain committed to abolishing slavery in all its forms..."(1)

1. https://www.state.gov/documents/organization/258876.pdf  
2. https://treaties.un.org/Pages/ShowMTDSGDetails.aspx?src=UNTSONLINE&tabid=3&mtdsg_no=XVIII-12-a&chapter=18&lang=en  
3. www.who.int/iris/bitstream/10665/77394/1/WHO_RHR_12.42_eng.pdf
4. http://www.unodc.org/unodc/en/human-trafficking/index.html?ref=menuside 
5. https://publications.iom.int/system/files/addressing_human_trafficking_dec2015.pdf