June-July 2017, Vol. 8, Issue 2
In This Issue


Arizona Psychiatric Society
Newsletter Committee
From the Newsletter Editor-in-Chief

Mona Amini, MD, MBA, FAPA

Dear Psychiatric Colleagues:

Summer greetings to you all! As the temperatures rise, so has our anxiety level related to the future of healthcare. As it is pertinent for our voices as psychiatrists to be heard, please assure you are contacting our State Senators in garnering their attention on this matter. We must work in a collective effort to raise the awareness not only to our legislators but also to the public, regarding the need for education in mental health and the attention in the healthcare setting that is so deserves. Legislative and policy efforts are highlighted throughout this newsletter.

In this edition of our newsletter, we meet Dr. Joseph Bloom, a forensic psychiatrist from Oregon now making his home in Arizona, who brings with him a passion for understanding the Arizona commitment laws, and whose exemplary contributions to forensic psychiatry were recognized at the APA Annual Meeting with the Isaac Ray Award. We also share other highlights from the APA Annual Meeting held in San Diego, California, including one of our two newest Distinguished Fellows, Dr. Marcelle Leet (Dr. Roland Segal being the other); Arizona Assembly Representatives Drs. Payam Sadr and Jasleen Chhatwal; and the opportunity to speak with U.S. Representative Tim Murphy at the Presidential Reception. Dr. Espinoza shares the educational highlights from the INES Annual Meeting, which coincides with the APA Annual Meeting.

Congratulations are in order for some members of our society, as well as our very own APS Lobbyist, Mr. Joe Abate. Mr. Abate was recently awarded the Maricopa County Republican Party Lincoln Lifetime Achievement Award, presented by US Congressman David Schweikert. See the photographs from the APS Annual Meeting awards, among them, Dr. Jehangir (Jay) Boman Bastani receiving the Career Achievement in Psychiatry Award in a very meaningful presentation from 2016 recipient and close colleague Dr. Martin Kassell, and Dr. Ron Wright from University of Arizona College of Medicine - Tucson receiving the Howard E. Wulsin Excellence in Education Award.

The Annual Meeting brought members together for a great day of education and collegial connection. Peer poster presentations were shared by Drs. Gwen Levitt and Eric Hegybelli and the juried Resident-Fellow Member and Medical Student posters were enjoyed by all (congratulations to the poster winners celebrated here).

We are thankful to Dawn Noggle for the informative updates on Arizona's participation in the Step Up Together initiative. Arizona celebrates being the first state to have 100% participation by County. Please note the upcoming Step Up Together Arizona Summit.

The Newsletter shares highlights of other CME and educational offerings. We encourage you to take a look at the great speaker line-up for the University of Arizona "Neuroscience of Enduring Change" conference from September 15-16 in Tucson.

Lastly, our very own Dr. Robin Reesal shares his always enlightening and poignant editorial, this time focusing on the abuse of women around the world. A heartfelt welcome back to he and his wife, who have extensively traveled the globe over the last few years with likely an abundance of stories of their tenure.

Sending cool thoughts your way!


At the APA Annual Meeting, Arizona's newest Distinguished Fellows (Dr. Marcelle Leet and Dr. Roland Segal), Fellows (Drs. Mona Amini, Sandra Jacobson, Saul Perea, Sami Victor, John Zaharopoulos), Life Fellows (Drs. Pamela Frazier and Lawrence M Martin), Life Members (Drs. Mary Nowlin, Stephen Herman, Howard Mason, Narendra Chauhan, Shelley Doumani-Semino, and Balbir Sharma), and 50-Year APA Members (Drs.
Joseph Bloom MD,  Ronald Nazareth, and  Robert Cottor)  were recognized in the Convocation. For information on becoming a Fellow of the APA, visit . Applications are due by September 1st.  


As I begin my year as President, I look back with great admiration to the wonderful leaders from my past who have helped shape my leadership style, professional focuses and future passion projects. Many of these leaders are members of the Arizona Psychiatric Society, whom quickly welcomed me in as both a member and as a leader when I joined six years ago. 

I received my medical training in New Orleans before, during, and after Hurricane Katrina. I experienced first-hand the importance of Psychiatrists working collaboratively with local government, first responders, and community partners to meet the needs of those affected. Working with the Arizona Psychiatric Society's Disaster Psychiatry Task Force, we have established connections and developed relationships with Coyote Crisis Collaborative, Centerpoint for Hope's Mobile Disaster Response, and the American Red Cross. As President, it is important to me to continue to build inroads for the Society to facilitate local disaster response.
In my work at Valley Hospital, we are confronted daily with the growing opioid epidemic and the catastrophic impact it has on those it touches. As Psychiatrists, we not only play an integral role in treating patients with opioid dependence but also in working with local government and public health to develop policy regarding education and prevention. This year, the Arizona Psychiatric Society will have this issue as top priority.  

The common thread that ties these areas of emphasis together for me is collaboration. Together, as well as working with our behavioral health allies, we can have a significant impact in these areas.

Your thoughts on the type of events, venues, or topics for the 2018 Annual Meeting (and its format) are always welcome. The Society works diligently to provide the value of membership to each one of you. If you have any suggestions or wish to become involved in any Committee of the Arizona Psychiatric Society, your voice and your leadership contributions are always welcome. Please contact either myself or Teri and we will be happy to listen, assist, and/or share your recommendations.

Again, I greatly look forward to working with you all this year to advance the objectives of The Arizona Psychiatric Society.


Aaron Wilson, MD
President, Arizona Psychiatric Society, 2017-2018



The Arizona Psychiatric Society signed on to a joint letter to the Arizona Senators Flake and McCain by Arizona medical associations, led by the Arizona Chapter of the American Chapter of Physicians (ACP), and also joined by leadership from the Arizona Medical Association, Arizona Osteopathic Medical Association, Arizona State Association of Physician Assistants, Arizona Chapter of the American Academy of Pediatrics, Arizona Chapter of the American College of Obstetricians and Gynecologists, and the Pima County Medical Society. The letter urged the Arizona Senators to vote to protect access to care in Arizona.  

Y our e-mails, calls, and social media posts were material to the vote on the Senate version of AHCA (BCRA) being pulled for a vote prior to the 4th of July break.  Senate offices track phone calls and respond to social media--your calls and action do count!  Your continued advocacy is needed to help support the best possible healthcare access for Arizonans.  CLICK HERE to contact your Senators.  Or engage directly through social media posts.  #protectMH #protectSUD  

Attached is a name card for Senator Flake or Senator McCain with each Senator's social media platforms. With the potential impact to Medicaid (AHCCCS) in the State of Arizona, the Arizona Senators could be decisive votes.  Please use the hashtags included to tell them why voting for BCRA would hurt 22 million people and strip mental health and substance use disorder coverage from our patient populations.  
PRMS_ Inc.


Joseph D. Bloom, MD, DLFAPA
I grew up in NYC, attended Columbia College, and was graduated from the Albert Einstein College of Medicine in 1962. I had a rotating internship at the Mt. Zion Hospital in San Francisco and completed residency training at the Massachusetts Mental Health Center in 1966, then served 2 years as the first psychiatrist assigned to the Indian Health Service in Alaska during which time I began a career long interest in transcultural psychiatry. I then went on to pursue a fellowship in Community Psychiatry at Harvard Medical School. In 1969, my wife and I and our 3 children returned to Alaska where I worked in a private practice for 8 years during which I began to do forensic work. Having a long term interest in academic psychiatry, in 1977 I joined the Department of Psychiatry at Oregon Health and Sciences University (OHSU), first as director of the Community Psychiatry Training Program, then in 1983 as Chair of the Department of Psychiatry. From 1993-2001 I served as Dean of the OHSU School of Medicine. For many years following 2001 I taught in the OHSU forensic fellowship program, practiced clinical and forensic psychiatry, and wrote articles focused on transcultural psychiatry and public psychiatry and the law, particularly on empirical studies on how statutes in these areas actually work in practice in Oregon and nationally. 
My main professional organizations have been the APA and the American Academy of Psychiatry and the Law (AAPL). I have served on many APA committees and was President of both the Alaska District Branch and the Oregon Psychiatric Association (OPA). I was a member of the Legislative Committee of the OPA for 35 years. I joined AAPL in 1974, and served as President of that organization in 1989-1990.

In 2015, my wife and I moved to Scottsdale. I recently was appointed Clinical Professor of Psychiatry at the University of Arizona, College of Medicine-Phoenix. Over the past 1.5 years I supervised two Banner psychiatric residents, Drs. Wanda Shao and Scott Kirkorsky, focused on issues related to forensic mental health services here in Arizona. I am no longer practicing psychiatry, but remain interested in issues related to public psychiatry and the law, including a focus on civil commitment of the mentally ill and sexually dangerous, competency to stand trial and competency restoration, the insanity defense, the right to refuse treatment, and on issues related to hospital and community care of these populations. Arizona mental health law has unique aspects which I will continue to try to master. I retain a continuing interest in teaching and in forensic mental health services research and writing and welcome contact with Arizona psychiatrists interested in these areas. My e-mail address remains


Captured in the photos below, APS celebrated the best from its members at the 2017 Annual Meeting, with (1) Dr. Brandon Yates presenting the Howard E. Wulsin Excellence in Education award to Dr. Ron Wright of University of Arizona College of Medicine, Tucson; (2) Outstanding Resident Recognition Awards being presented by Dr. Marwah, on behalf of each Residency Program, to Dr. Wanda Shao, Banner UMC Phoenix, Dr. Beth Darling, MIHS, and Dr. Brandon Yates UofACOM, Tucson; (3) and (4) Dr. Martin Kassell presents the Career Achievement Award in Psychiatry to Dr. Jehangir Jay Boman Bastani, MD, DLFAPA.  

Bottom Photo:  Dr. Marwah recognizes the outstanding leadership contributions of Dr. Ole Thienhaus (upper left) and Dr. Carol Olson (lower right); and Dr. Aaron Wilson thanks Dr. Marwah for her exemplary service as President (upper right).  


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

Arizona achieved a landmark in May becoming the first state in which every county signed a Stepping Up Proclamation with La Paz signing in May! Tireless advocacy to reduce the incarceration of the seriously mentally ill by volunteer led David's Hope made this possible. Natassia Walsh, the Stepping Up National Coordinator, and featured guest speaker for the August Statewide Stepping Up Summit, is calling Maricopa County next week to hear more about our efforts which are attracting national attention. Join leaders across the state to hear more and contribute by attending the Summit. Across Arizona, Counties, in tandem with the Regional Behavioral Health Authorities (Health Choice, Integrated Care, Mercy Maricopa Integrated Care and Cenpatico Integrated Care) continue to bolster training and resources for officers to avoid unnecessary jail bookings, to increase diversion opportunities once mentally ill individuals are brought to jail and to strengthen connections to care upon release to interrupt this revolving door that so negatively impacts the lives of individuals who need treatment and social supports rather than incarceration.

Stepping Up acknowledges that we must address individuals with substance use disorders (SUD). As with the seriously mentally ill, these are predominately low risk individuals who wind up in jail accused of nonviolent offenses, rather than directed to "solutions", effective treatment and support for problematic substance use. Less guidance has been offered in the Stepping Up Toolkit specific to addressing this population.  

At Maricopa County, as part of Stepping Up, Correctional Health Services decided to actively address substance use in the jail population. We implemented the SAMHSA best practice SBIRT (Screening, Brief Intervention and Referral to Treatment) in March 2016. This has been an ongoing effort over the past 15 months involving changes to our electronic health record (to incorporate evidence based screening questions) and training of all mental health and nursing staff to screen all individuals (remaining past the 24 hour Initial Appearance Court). We have also, with the help of Public Health, are training mental health staff and medical/psychiatric providers in "brief interventions", and are increasing referrals to substance misuse treatment while incarcerated (CHS Intensive SUD program, Mosaic (see video link) and referrals to community agencies upon release, including "warm hand offs" to increase service engagement. A shift to Motivational Interviewing is foundational to SBIRT and all strategies addressing substance use/misuse. Providing educational materials and encouraging abstinence alone, we know, are failed interventions. As our electronic health record reports are completed, CHS will be able to routinely report and trend substance use and misuse, brief interventions and treatment referrals and ultimately the impact on overall jail recidivism. Fundamental to all Stepping Up efforts is the 2 pronged approach to develop baseline data (e.g. number of SMI designated; number of individuals at risk for and having SUD) and to measure impact of interventions on decreasing the use of jail for a low risk population better served in the community. Maricopa County was awarded a National Association of County Organizations (NACO) Achievement Award in June 2017 for this implementation.

Stepping Beyond: Meeting the Opioid Crisis Head On

Across the nation we know from CDC data that in 2016 there were at least 60,000 deaths related to opioid use. The CDC has called this the worst drug overdose epidemic in our history. In Arizona 790 died from opioid overdoses, an increase of 74% over the past 4 years. In recognition of Arizona's becoming one of the most impacted states, on June 5, 2017 Governor Doug Ducey declared a Public Health State of Emergency.
The Governor's Initiative calls for the following steps:

* prevent prescription opioid drug abuse through appropriate prescribing practices,
* develop guidelines to educate healthcare providers on responsible prescribing practices,
* expand access to treatment, especially Medication Assisted Treatment (MAT), and
* reverse overdoses through the distribution of naloxone.

The governor is also requesting up to date reporting by Counties and agencies across the state for more "real time" information regarding overdoses, deaths related to overdose and attempts to reverse overdose (e.g. via naloxone and narcan). In response, Maricopa County Public Health is coordinating our County's reporting to the Governor's Office suspected opioid overdoses and administration of naloxone.

Recommendations for a "full spectrum" public health response to the opioid crisis are being established (such as the Drug Policy Alliance June 2017 document Echoing Stepping Up, there is a call to increase access to community based effective treatment, especially for individuals with greatest social determinant risk; to increase education to reduce stigma and to raise prescribe awareness; to increase harm reduction strategies focusing on safety and keeping people alive (over the outdated concerns that anything other than promoting abstinence is "risky"); and to decrease "criminalization" when community based treatment is the most appropriate response. Notably these recommendations are strongly urging harm reduction strategies such as increased availability for overdose reversal medications, including for law enforcement (e.g. naloxone) and family members along with those at risk. We must also increase the safety for IV drug users including safe injection sites and needle exchanges. 

Correctional Health Services has certainly been seeing the rising tide of opioid use. We have been actively tracking individuals reporting opioid use/dependence booking into our jails for the past 18 months. Our records show well over 900 individuals per month reporting ongoing opioid use (with our average daily census floating around 8,000). We have implemented a "full spectrum" approach involving continuation of Medical Assisted Treatment (MAT) for individuals on methadone treatment in the community which includes coordination of care and warm transfers upon release. Despite lingering negative responses by some quarters, methadone, as an agonist treatment, has been established through research to prevent relapse back to illicit substances and to decrease further criminal justice involvement. Despite this, only 12% of opioid dependent individuals are engaged in such treatment. CHS also provides in custody intensive substance use disorder treatment (Mosaic Program-see video). 
Stepping Beyond:

Most recently, CHS has begun a multi-agency Vivitrol Pilot (including Darwyn Chern, MD, Chief Medical Director of Partners in Recovery and AZ Society of Addiction Medicine Board Vice President, Saul Perea, MD, Terros, Charles Booker, MD, CleanSlate, and representatives from Community Bridges, Cross Roads, Maricopa County Adult Probation, the Maricopa County Sheriff's Office (MCSO), and Community Medical Services. Candidates who have completed intensive treatment and who agree to continue treatment with one of the above community partner agencies will receive a Vivitrol injection prior to release. Vivitrol, an antagonist treatment, is known to reduce cravings and can be administered monthly. Arizona Department of Corrections has also begun administration of Vivitrol for consenting individuals with Opioid Use Disorder, prior to prison release. This treatment provides a safe bridge to the most important next step, ongoing psychosocial and pharmacological treatment. Yavapai County Jail has already successfully implemented such use of Vivitrol and Mohave County is in planning stages. 
Beginning July 1, CHS is taking another critical step in the battle to reduce overdose deaths. Leaving jail and prison is a known high risk time for overdose. Individuals who have been abstinent for a period of time can easily overdose. Returning to a dose previously tolerated can be fatal. Perhaps the "supply chain" poses the greater risk as it contains opioids and synthetic derivatives, such as fentanyl, 50 to 1,000 times stronger than typical heroin, easily available through the "dark web". CHS will begin distribution of naloxone "kits" for opioid dependent individuals, not on MAT, releasing from custody. We are budgeting to provide 400 kits a month, which indicates how serious this problem is in our community. Our initial July supply is being provided by Sonoran Prevention, the agency that has been out there providing education and reversal kits to law enforcement across the Valley. Haley Coles, Sonoran Prevention Director, reports that between September 2016 and end of May 2017, her staff have distributed 9,131 naloxone kits and received reports of them being used to reverse an overdose 822 times. 538 kits have been provided to law enforcement between January 2017 and end of May 2017. In addition, Sonoran Prevention, in tandem with Maryvale Police Department, began a needle exchange program providing clean syringes, a program known to reduce risk of infectious disease. Such harm reduction efforts are essential to reversing the disturbing trends we are witnessing in Arizona and across the country. Sonoran Prevention is essentially a behavioral "start up" agency designed to address this crushing and previously unmet community need. With a bare bones staff and without a "bricks and mortar" office, Arizona may yet see a slowing if not reversal of overdose deaths in 2017 with their efforts and law enforcement's decision to serve as first responders. Time will tell as data is collected. 

Stay tuned for more on other steps we will all be taking to address the opioid epidemic. New efforts will be seeded by the federal Health and Human services STR (State Targeted Response to the Opioid Crisis) grants, one of two rounds of funding to be provided to states under the SAMHSA administered 21st Century Cures Act. According to Shana Malone, AHCCCS's leader and architect for this campaign: 

"AHCCCS and partnering state agencies, health plans, universities and community providers will soon be launching statewide prevention and treatment activities through the Opioid STR grant to address the continuum of opioid misuse, abuse and dependency."

More to come in the next Stepping Up update!

The Arizona Psychiatric Society thanks Dr. Noggle for her comprehensive updates that 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 updates and the 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.  


Early Bird Rates through July 10; Register by August 15

Join with criminal justice and mental health stakeholders from across Arizona as they come together to share the successes and challenges in reducing the number of people with mental illness and addiction who are incarcerated. Criminal justice / mental health professionals, public officials, peers, family members and all concerned community members are invited to converge for a time of learning, sharing and development of the principles and practices being used to promote and implement the national Stepping Up Initiative throughout Arizona.

Keynote speaker will be Nastassia Walsh, Program Manager for County Solutions and Innovations at the National Association of Counties. In this role, Nastassia is primarily responsible for managing Stepping Up: A National Initiative to Reduce the Number of People with Mental Illnesses in Jails. Prior to joining NACo, Nastassia was a senior policy analyst at the Council of State Governments Justice Center where she provided training and technical assistance to state and local criminal and juvenile justice agencies to develop programs for people returning to their communities from jails and prisons. She also spent 6 years at the non-profit Justice Policy Institute researching local, state, and federal criminal and juvenile justice policies.
Also featured, Senator Nancy Barto will share her efforts to improve the state's mental health system. Yavapai County's top Sheriff and President of the Western State's Sheriff Association, Scott Mascher, will be sharing his vision for creating linkages to treatment for people with mental illness and addictions.

Two day summit registration includes continental breakfast, lunch and afternoon snacks both days. Awards Dinner on Thursday is also included. Early bird prices available through July 10.

On Thursday August 24 - 4:30 - 6:30pm we will be hosting our Law Enforcement - Mental Health Criminal Justice Collaboration Awards Dinner and Ceremony. Summit registration also includes the awards dinner. However, if you are unable to attend the two day summit, yet would like to participate in honoring the 2017 David's Hope award winners, Awards Dinner tickets may also be purchased separately.

The Mental Health Guild, a 501(c)(3) corporational originally formed as the fundraising guild of The Mental Health Association of Maricopa County from 1964-1985, shares its congratulations to MENTAL HEALTH AMERICA of ARIZONA, the oldest mental health citizen's advocacy organization in Arizona & America (1954 - 2017), for its successful 2017 MHA AZ Annual Seeds Conference, "Navigating the Hurdles: B4STAGE4."  The first Seeds Conference was in 1988.  The Mental Health Guild provided ten scholarships to the Seeds Conference honoring Dr. Max Dine, APS Community Liaison, MHA Board Member, and Great Mental Health Advocate.  CLICK HERE for highlights of the Seeds Conference.  

Payam Sadr, MD, FAPA, Arizona Assembly Representative
Jasleen Chhatwal, MD, Designated Arizona Assembly Representative
Arizona was fully represented at the APA Annual Meeting Assembly by Dr. Payam Sadr and Dr. Jasleen Chhatwal.  

Highlights of the CEO/Medical Director's report included the update on the new APA offices, which should be ready in 2018, and APA's registry now accessible for QI and to increase CMS revenue for psychiatrists. Dr. Levin also emphasizes Assembly initiated APA accomplishments, such as the APA accreditation as a consulting NGO to the United Nations; creating new CPR codes for reimbursement; increasing diversity in membership in the Assembly; and Assembly led call for MOC reform, which has now led to at least 13 states proposing or passing removal of MOC legislation.

For a full report on the Position Statements adopted and Action Papers considered, please CLICK HERE to view the Assembly Notes.

One of the most engaging work group reports, that of the MOC Committee, represented by L. Russell Pet, M.D.: The Assembly supported unanimously the recommendation of the MOC Committee for the APA to adopt a position that decisions regarding licensure, hospital privileges, and credentialing and/or participation on insurance panels should not in any way be conditioned upon the physician's completion of or participation in MOC or Osteopathic Continuous Certification. This is consistent with the position of the ABPN and would significantly reduce physician burnout. The Assembly further supported unanimously that the position be brought to the BOT at the earliest opportunity (July 2017) for their approval on this position.
ArMA HOUSE OF DELEGATES: Aaron Wilson, MD, and Brian Espinoza, MD, APS Delegates

Psychiatry was well represented at the Arizona Medical Association (ArMA) 2017 Annual Meeting and House of Delegates.  In the photos, upper left, Dr. Gretchen Alexander (Past President of the Arizona Psychiatric Society (APS)) concluded her year as President of the Arizona Medical Association and welcomed in new President Dr. Michael Hamant; standing in the middle of the photo upper right, Dr. Rodgers McKinley Wilson was a delegate for Maricopa County Medical Society (MCMS); lower left, Dr. Lee Ann Kelley, as delegate for MCMS, with Dr. Brian Espinoza, as delegate for APS (APS also represented by Dr. Aaron Wilson, not photographed).  Among the award highlights, Representative Kate Brophy McGee was awarded the ArMA Walk the Talk award for her work on health-related legislation.  Dr. Hamant's focus during his presidency will be on promoting physician leadership and countering burnout, through establishing better community connections.  The House of Delegates Resolutions presented were on a wide range of topics, from sunsetting the critical issues in Arizona medical education, to promoting more graduate medical education funding, tobacco, cannabis, and end of life task force, among others.  A resolution was also adopted for the creation of a Medical Student section, Resident and Fellow Section, and Young Physician Section within ArMA.  


Governor Ducey issued an executive order June 13 calling for immediate action in the state's opioid emergency response. The executive order requires opioid overdose and death data to
be reported to the Arizona Department of Health Services within 24 hours of the event, effective June 15.

"In addition to the data collection, we are currently working to train over 700 law enforcement and emergency medical services, or EMS providers, on naloxone administration," said Dr. Cara Christ, director of the Arizona Department of Health Services.  "Our training will expand to public health, clinicians, and pharmacists, to share knowledge on overdose recognition and treatment, naloxone administration, opioid-related reporting, appropriate prescribing practices, and medication assisted treatment."

Under the Governor's executive order, five main categories of data will be collected including opioid-related overdoses and deaths, naloxone doses both administered and dispensed, and cases of neonatal abstinence syndrome. During the first week of reporting, 18 incidents of neonatal abstinence syndrome were reported for newborns suspected of undergoing opioid withdrawal symptoms. Additional data collected shows emergency responders administered 102 doses of naloxone, the overdose reversal drug. Arizona pharmacists dispensed 51 naloxone kits to those at high risk of overdose.

The Arizona Department of Health Services will update opioid-related reporting to its website every Monday. Information on training, reporting requirements, opioid information, and frequently asked questions may be found throughout the website.  The first week of collected data is represented in the graphic at right.  

As of June 2, 2017, the Centers for Medicare and Medicaid Services (CMS) has indicated that currently there is only a path forward for an IMD waiver for individuals with substance use disorder needs, as part of a comprehensive state substance use disorder (SUD) strategy. AHCCCS will move forward with the submitting such comprehensive strategy, and will comply with the IMD provisions of the managed care regulations for individuals with non-SUD behavioral health conditions.  In the upcoming weeks, AHCCCS will revisit strategies identified by MCOs and providers to continue discussions related to compliance with this regulation.


We celebrate the following RFM and Medical Student Poster presenters from the APS Annual Meeting:  

First Author: Jeffrey Burrow, MD, PGY-2, Banner UMC Phoenix
Secondary Authors: Stephen Mecham, DO, Amal Sharifi, MD
Topic: Catatonia, Psychosis
Title of Poster: An Atypical Antipsychotic and Benzodiazepine Used to Treat Haloperidol Induced Catatonia: A Case Study (3rd Place; photo 2nd in left column)

First Author: Maya Heck MD, PGY-1, MIHS
Secondary Authors: Devnandini Rastogi MD
Topic: Medication adverse effect; treatment of schizophrenia; first generation antipsychotics
Title of Poster:  Transaminitis in a Patient with Schizophrenia Treated with Loxapine: A Case Report (Photo 2nd in right column; 3rd in left)

First Author: Marie Roy-Babbitt, MD, PGY-2, MIHS
Secondary Authors: Mamuna Ahmad MD, Steven Kwoh MD, Gwen Levitt DO
Topic: Bipolar disorder, treatment resistance
Title of Poster:  Treatment-Resistant Ultra-Rapid Cycling Bipolar Disorder: A Case Report (Photo 2nd in right column; 4th in left)

First Author: Arielle Eliz Rubin, B.A., MSIV, University of Arizona College of Medicine Phoenix
Secondary Authors: Francisco Moreno M.D., Associate Vice President, Diversity and Inclusion at University of Arizona College of Medicine Tucson, Professor of Psychiatry
Topic: Latina mental health, Trauma exposure during immigration journeys and resilience, Depression in Hispanic undocumented female immigrants
Title of Poster:  "El Viaje Al Otro Lado":  Relationship Between Depression Onset in Latinas and Immigration Experience Coming to the United States (2nd Place; 1st photo in right column; 4th photo in right)

First Author: Wanda Shao, DO, PGY-4, Banner UMC Phoenix
Secondary Authors: Shehzad Ayub, DO; Will Heise, MD; Richard Gerkin, MD
Topic: psychopharmacology
Title of Poster:  QTC Prolongation and TDP Associated with Psychiatric Medications: A Retrospective Cross-Sectional Study of Adult Inpatients (1st Place; Photo top left column; 3rd in right column)

Special thanks to the poster judges, Drs. William James, Ole Thienhaus, Tariq Ghafoor, and Gagandeep Singh, and thanks to the meeting attendees who took the time to complete the peer poster feedback.  
CME AND EVENTS:  UofA Neuroscience of Enduring Change 9-15 to 9-16; APA Free Course of the Month; PCCS-O and PCSS-MAT Free Opioid Education 

Each month APA makes available a free CME course exclusive to members only through its Learning Center. July's Course is "Identifying and Managing Cardiac Safety Risks of Psychotropic Drugs."  This course presented by Carrie L. Ernst, M.D. of the Icahn School of Medicine, reviews fundamental information for psychiatrists regarding cardiac safety considerations for patients taking psychotropic drugs. CLICK HERE for more information.

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

PCSS-O and PCSS-MAT have trained more than 100,000 clinicians in preventing, identifying, and treating opioid use disorder, but did you know that these free resources are available to you through these two federal grant projects. VIEW THE FLYER for more information on the training (including podcasts) and mentoring, all by experts in the field.  
May 21, 2017 - San Diego, California

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

ISEN membership has leveled out at about 300, possibly, as TMS clinicians have recently formed their own Society. This was my ninth year in attendance, and the morning was spent with presentations on cognition and ECT. The afternoon was spent in breakout Workshops and Abstract Presentations.

Morning Symposium-Understanding and Improving the Cognitive Outcomes of ECT

* Cognitive Effects of ECT: A Patient's Perspective-the most effective educational tool in the patient speaker's opinion was having a prospective patient talk with a current ECT patient about their experiences (working on that)

* Overview of Cognitive Effects After a Course of ECT: Evidence From Meta-Analysis of Studies
Time to reorientation has been correlated with ECT Short Term Memory Loss (STML). Old wives
tale; need to stop Lithium for ECT; NO, Lithium may delay time to full reorientation, but no overall
detrimental effect; maybe hold the day before as ECT transiently increases Blood-Brain-Barrier
permeability (i.e. a rush of Lithium in CSF); need to analyze on a case by case basis (Lithium, like
ECT has unequivocal anti-suicidal properties). Frontal Executive Function is the most effected by
ECT. A 2017 met-analysis shows that the least impact on memory is the use of Ultra-Brief Pulse
Unilateral ECT on a twice weekly basis (however, these were not our typically encountered
patients in the community; acutely suicidal/psychotic patients with minimal support/resources).

* Practical Clinical Tools for Monitoring Cognition
Several rating scales were discussed on measuring cognition; this area is driven by the upcoming
reclassification issue with the FDA, and we will likely be mandated to track (we know about ECT
cognitive impairment, we know how to assess and manage; now another government mandate
that shows no purpose other than data collection and federal job creation)
mMSE vs. MoCA; MoCA preferred as better for assessing anterograde memory and executive
function. Time to reorientation after ECT appears to be a good predictor of amnesia so a "10 item
Orientation questionnaire" has been developed. Other tools include a BECS (Brief ECT Cognitive
Screen), and a 2-item SAMI (Subjective Assessment of Memory Impairment). A study looking at
verbal fluency being a predictor of Retrograde Amnesia is underway. 

* Development of a New Clinical Scale for Measuring Cognitive Outcomes After ECT
The ECCA (ECT Cognitive Assessment) has been developed and is being studied at Emory
University. 4 to 6 minutes to administer; would replace the mMSE & MoCA; can be done over the
phone (an advantage during the mid- and tail-ends of an ECT course if a patient or caretaker
should call with concerns); appears to have greater sensitivity during ECT than the MoCA. There
are further studies underway comparing to the mMSE, MoCA, and Neuropsychological Testing.

Concurrent Afternoon Workshops (participants could choose 2 of 4 available)
* TMS and New Brain Stimulation Treatments
New Developments in TMS: TBS (Theta Burst Stimulation), Novel Stimulation Targets
TBS is an amped up version of TMS that shortens the treatment to 3 minutes. This is being used
as the sole source of TMS in Toronto, as, thanks to Socialized Medicine there are no Private
Clinics that offer TMS in any form, and, a more rapid delivery is needed given the population
needing services. They are now looking at delivering multiple treatment sessions a day to
speed up response time. They are also looking at Neural Defined Endophenotypes of
Depression (Salience or Cognitive Network, a Reward Circuit, and, Non-Reward Circuit), and
examining if adjustment of magnet placement improves results.

Update on DBS (Deep Brian Stimulation) in Depression and OCD
As previously reported, 2 controlled trials failed to show improvement in MDD; both device
makers (Medtronics and St. Judes's) have pulled out of development. DBS remains strong for
Parkinson's Disease with over 130K patients implanted, and, is still reimbursed by Medicare for
TR-OCD under a Humanitarian Device Exemption (ECT failure is no longer a criteria for DBS
implantation in TR-OCD).

What remains new and exciting is DBS based on a Closed Loop System. The study that I
reported on last year is underway (at $500K/month with a funding of $300 million) where a
matchbox size send and receive device is cranially implanted with a drop down umbrella
of deep brain electrodes. The hunt for behavioral domains is on under RDoC (NIMH Research
Domain Criteria), and once mapped out, hopefully, one day, when a pathologic circuit fires, DBS
will "fire back".

MST (Magnetic Seizure Therapy) & FEAST (Focal Electricallly Administered Seizure Therapy)
Reported on last year, not much new other than a new MST device targets the Motor
Strip to induce seizures. It looks like it will equal Unilateral ECT in effectiveness. One setback
is it takes over 20 treatments to produce results, and another difficulty is getting sufficient
dosing into the brain. Not much going on here.

FEAST differs from ECT; the current is unidirectional, and electrode placement is asymmetrical
with novel placements still being explored.

Both of these approaches are still to be considered experimental.

I believe, as do the International Experts, the more focal and less cognitive impairing the modality, a drop in effectiveness rate ensues. So it is imperative upon us to take this into consideration in our
procedural approaches (memory loss is better than life loss).

If I can be of any help in sorting out the above, please contact me. 

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.    
APA HIGHLIGHTS:  New Telepsychiatry Toolkit; Video Explains PsychPro (APA's Mental Health Registry)

APA's Telepsychiatry Toolkit - developed by the APA Work Group on Telepsychiatry - is an evolving resource for members who want to learn about the various aspects of telepsychiatry, including clinical, training, and policy considerations. As new topics emerge, more resources and information will be added to this toolkit.  The toolkit covers topics from History, training, practice/clinical, reimbursement and legal issues from leading psychiatrists.

Video Explains PsychPRO, APA's Mental Health Registry
Curious about PsychPRO, the new mental health registry from APA? Click here to watch a short video that explains how PsychPRO can help you treat patients and meet your certification requirements. PsychPRO is open to individual psychiatrists as well as large group practices and hospitals.

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


Today's article focuses on the abuse or maltreatment of women around the world. My goals is to raise awareness about the variety, frequency and severity of this problem.  This article only touches the surface of this important and sensitive topic.

Case presentations

Case 1. A married Rwandan mother sought marital counseling because of verbal and physical abuse by her husband. She went through numerous social and legal steps to obtain custody of her children. She experienced ridicule for not being "a good traditional wife". Her former in laws made disparaging statements to ruin her reputation within her community. Legally, she was granted custody but receiving minimal child support from a judge. She looked for and found work in Europe where she lives happily as a single mother and sole provider for her children.

Case 2. A European single working professional woman, in her early thirties sought help for relationship issues with an African male. This man denied being with another woman, isolated her from her friends, used her financially and promoted dependency on him. He told her that her doubts about him were due to a mental illness. She was able to disengage from him, regain perspective and enjoy her life again.    

Case 3. Qandeel Baloch, a Pakistan social media star and feminist was tragically killed in 2016. CNN reported her brother as saying; "girls are born to stay home..."I am proud of what I did. I drugged her first, then I killed her...She was bringing dishonor to our family."  Through her death, Ms. Baloch was able to highlight the plight of women who will have a better life because of her.

Case 4. Ashton Kutcher, the actor recently stated, "We had received a call from the Department of Homeland Security telling us that a seven-year-old girl was being sexually abused and that content was being spread around the dark web and she'd was being abused and they'd watched her for three years and they could not find the perpetrator." This terrible case raises awareness of internet dangers and child safety.

Case 5. A Nigerian woman stated: "I am in my late 50s with shattered aspirations; no husband, no children or a family of my own due to the barbaric practice of female genital mutilation that was carried out on me when I was a two-year old,'' This woman's courage to voice her story publicly despite the intimate topic helps others feel less alone and promotes positive change.


The Department of Justice defines domestic violence as a "pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner".

To my mind, this legal definition captures the psychological underpinnings of abuse against women. Around the world, power and control is a common thread when abuse occurs. The above cases show the overt manifestations of these two factors.

Statistics on abuse  

In a 2016, Lancet Psychiatry article, Oram et al. described violence against women as a "prominent public health problem and violation of human rights".  

While violence is not limited to women, they are more often the recipients.  Worldwide, about 35% of women have experienced intimate partner violence or non-partner sexual violence. Worldwide, partners or ex-partners commit about 39% of murders of women.  This rate rises to 59% in Southeast Asia.

The few numbers presented above only highlight the large body of evidence supporting the frequency and severity of abuse against woman.

Female genital mutilation (FGM)

A recent legal case in Michigan has brought the issue of female genital mutilation to the forefront. Attached is a link from a journalist in the U.S. who described her life experiences within her sect of Islam, the Dawoodi Bohras. 

While families and cultural groups may not interpret female genital mutilation as an act of abuse towards a female, formal bodies such as the World Health Organization consider this practice as abuse. The practice involves the partial or full removal of external female genitalia.

UNICEF estimates that about 200 million women in 30 nations have been subjected to female genital mutilation. Practices vary within continents. For example, in Africa, the prevalence is 98% in Somalia, 93% in Djibouti, 90% in Sierra Leone, 89% in Mali, 87% in Egypt and Sudan. While other African countries have low rates such as Togo 5%, Ghana 4% and Niger 2%.

What is the relevance of violence against women?

Simply, abuse and violence against women is wrong.  

There are short term and longterm psychological and physical costs from abuse/maltreatment.  The consequences affect individuals, families and societies. The effects cross generations and can be culturally ingrained.

Research evidence suggests that women subjected to domestic violence can be three times more likely to suffer from depression, four times more likely to have an anxiety disorder and seven times more likely to experience post-traumatic stress disorder. There are also increased risks of substance use, eating disorders, psychosis and self-harm.  The effects on personality are lifelong.

Conclusions through my eyes

I am expected to provide a relevant photo to accompany each article. Some of the online photos of abused women were highly distressing. I googled "images abused women".  If looking at a photo was distressing, I cannot imagine what the abused women felt. Spending time in pathology, seeing patients in emergency rooms and living in some of the poorest countries of the world did not protect me from the emotional turmoil created by the photos. The accompanying photo from a U.S. government website promotes support and comfort.

Having visited and lived on several continents, my view, supported by the literature, is that a substantial number of women are abused, disempowered, disenfranchised and disproportionately burdened with responsibilities. Through it all, they find ways to provide a smile for their child and guide their families through turmoil. As psychiatrists, we have a great deal to offer women around the world.