CurrentOctober, November, December 2014 | Vol. 30 No. 4

ISSUESPresident’s message 1

Legislative report 2

HHP Portland reduces youth violence 3

Executive Council Highlights 4

Dramatically improved insurance coverage 6

Enchantment: Ashland 2014 8

When the actors’ panel for Into the Woods climbed on stage at the fall Oregon Psychiatric Physicians Association meeting in Ashland, Oregon, I realized that the Tree that had chastised me in a previous year was sitting less than 10 feet from me. Painfully, I recognized her the evening before on stage, but I thought there was no way she could see me in the audience, much less remember me. Now the opportunity to be in such an intimate setting with these professional actors was playing itself out in a new way.

A few years ago the Oregon Shakespeare Festival dubbed a season the “Into the woods” season; it included some avant-garde presentations including one in which we actually walked into the woods and listened to the actors, and another where there were several giant trees in the outdoor Shakespearean theater talking to each other. We walked from venue to venue, from the forest to the theater, having Tree Experiences. OK – I was taking pictures and got caught by one of the big trees in the outdoor theater. Fortunately, she was well rooted and could not run after me … my psyche would have never recovered from that.

Probably the best part of the Ashland conference is the actors’ panel. As clinicians we are used to hearing about the lives of our patients and following their development over time. In our dynamic work we contemplate the roles we play with our patients and what roles they might be taking on with us, and in their lives. With the actors’ panels we get to hear about how people have become actors and what it is like to take on new roles constantly as a professional. With repeated attendance at the Ashland festival we get to see the actors develop personally and professionally and literally transform as we follow their careers in the theater.

And how do the plays relate to our clinical care? Into the Woods reminds us that the stories of childhood play themselves out in our present daily lives as adults. Is that clinically relevant?

Several of the presentations at this year’s meeting were highly clinically relevant, and I also think were things that are not well CME’d in other venues. For me personally, after Dr. Jon Emens’ talk on nightmares, I am going to see if I can convince my therapist colleges here at the Portland VA Medical Center to learn and do Image

Rehearsal Therapy for nightmares; I am excited to have a rational response to what to do about nightmares. Dr. Doreen Dodge-McGee’s talks were also practice changing, in that I do need to be asking about the electronic media use by my patients; this has become a big part of most people’s lives and a source of new and sometimes complicated relationships. There was also the fantastic update of the DSM-V changes by Drs. Conant-Norville, Hansen, and Lockey, that was will be incredibly useful.

Not everything was, perhaps, directly relevant to my practice, but in a good way. As useful as it was, there were probably 20 CME meetings this year I could have attended that would have told me how to manage insomnia, but this meeting provided opportunities for learning that cannot be had anyplace else. Nowhere else can I easily get exposure to the analytic approach to fairy tales, or the forensic psychiatrist who has to spend his days determining if someone is lying. As I laughed through Dr. Scott’s funny talk about serial killers, it made me reflect on how many of my patients might be hiding something. It is fun to be reminded of, and get a glimpse of, these

by Annette Matthews, MD

PRESIDENT’S MESSAGE

(Continued on page 4)

Exploring the woods

2

OPPA Executive CouncilPresident

Annette Matthews, MD

President–ElectCraig Zarling, MD

SecretaryDaniel Dick, MD

TreasurerApril Sweeney, MD

Past PresidentsDavid Conant-Norville, MD

Chris Lockey, MDSatya Chandragiri, MD

APA RepresentativeAnnette Matthews, MD

APA Deputy RepresentativeAmela Blekic, MD

CouncilorsStephanie Lopez, MD Neisha D’Souza, MD

Simrat Sethi, MD

At Large Councilors Denise Dion, MD

Norwood Knight-Richardson, MD

Child Psychiatry RepresentativeKirk Wolfe, MD

Newsletter EditorScott Reichlin, MD

Lane County Chapter PresidentVictor Richenstein, MD

Psychiatric Residents’ RepresentativeKelly Cleaves, DO

Committee ChairpersonsCME

Scott Reichlin, MD

EthicsVictor Richenstein, MD

LegislativeDaniel Dick, MD

Member Assistance ProgramHenry Grass, MD

MembershipMark Kinzie, MD

ProgramLee Shershow, MD

Public Information & EducationDaniel Bristow, MD

OPPA StaffExecutive Director

Patrick Sieng

Government Relations DirectorAmy Goodall

Program Committee CoordinatorPatti Legarda

OPPA Contact:phone/fax: 503-406-2526

info@oregonpsychiatric.org

Uncertainties and mysteries for the 2015 legislatureby Amy Goodall, OPPA lobbyist

October 2014 is a uniquely chaotic time for the Legislative Committee. With less than one month until the election and pre-session filing deadlines passing for 2015 legislative concepts, legislators and candidates are juggling campaign work and policy development. There are several tight races across the state in the House and the Senate, leaving uncertainty about what the Democrat to Republican ratio will be in each chamber. The outcome of the election will also affect committee membership, chairs, and other leadership positions.

The Senate Health Care Committee already has begun discussing Mental Health issues during interim meetings. The topics include program funding, adolescent suicide prevention, and addictions and mental health. Both Health Care Committees have continued to receive updates from the Oregon Health Authority regarding the transition away from anything related to Oracle, the provider for Cover Oregon. Open enrollment in the plans that have been approved, approximately 10-15 different choices, begins on November 15th and runs through next February 15.

Many of the issues mentioned above will produce legislative concepts that will become bills for the 2015 session. There will be hundreds of additional bills related to service delivery, prevention programs, and other topics that will go through the Health Care Committee. Some issues already discussed include telemedicine, physician dispensing, and anesthesiology assistants.

In addition, the Judiciary committees, especially in the House, are expected to address issues with Oregon State Hospital, incarceration, and other issues pertinent to OPPA. Our legislative committee has met with legislators involved in Health Care and Judicial issues in preparation for the session. OPPA may be introducing legislation for the Judiciary Committee and will be ready to respond to issues brought forth by others, in support or opposition.

Finally, the legislative committee has been following the interim task force that was created in 2013 by HB 2902 with the charge of addressing pay parity for primary care and mental health services. The bill required that nurse practitioners (NP) and physicians’ assistants be paid the same amount as physicians for performing the same services. The bill was in response to a health insurer who had reduced payment to NP’s. The legislation was intended to be a temporary fix so that providers would continue to see patients (especially in areas where physicians are difficult to access) while the task force came up with alternative solutions. The bill has a sunset, so unless additional legislation is passed to either remove the sunset or implement a new policy, HB 2902 will sunset in 2018. The group is required to submit a report to the legislature with recommendations in 2015. The task force will be making policy recommendations to the legislature, but at this point they have not officially developed and voted on what they are going to submit. OPPA has been actively engaged with the group, in particular, expressing concerns over removing the sunset clause without further policy changes that address a myriad of concerns with the statute as it stands. Depending on the final report and recommendations OPPA will respond and engage legislatively as needed.

LEGISLATIVE REPORT

3

HHP Portland reduces youth violenceby Alisha Moreland-Capuia, MD

Portland has a gang problem, but inside the gang problem, there is a youth trauma and violence problem. According to data obtained from the Portland Police Bureau Youth Gangs Unit, which tracks all violent crimes, between March and October 2013 violence among young males of color increased by 40% compared to the same months the previous year, increasing from 20 to 34 gang related interpersonal violence incidents.

Inspired by the Healing Hurt People (HHP) program in Philadelphia a similar program launched in Portland in June 2013. HHP Portland is a trauma-informed, community-focused youth violence prevention program that serves young males of color between the ages of 10-25 who have suffered a penetrating trauma. The point of intervention is the emergency department, within a 4-hour window, an evidence-based, well researched time frame for effective violence intervention deemed the “golden moment.” This is the time that victims are most poised to consider healthier alternatives to retaliation and more willing to move away from violence and towards healing.

The golden moment is powerful and must be handled with skill and care, which is why persons working for HHP are trained in trauma-informed care. Victims of violence and their families are compassionately engaged within the trauma bay and during their hospital stay. Upon release from the hospital, victims and their families are engaged for six to twelve months; they are provided with wraparound services and therapy.

HHP Portland is a partnership between Cascadia Behavioral Healthcare and Legacy Emanuel Hospital. At its core it entails a strong and intricate partnership among Legacy Emanuel social workers, chaplains, trauma physicians and surgeons, emergency room physicians and nurses, community peer workers, community injury prevention specialists, law enforcement, and city and state government. All of these parts work together to reduce and prevent youth violence in a partnership for collective impact.

Our physician-managed, multi-specialty group of 1,100 physicians who care for 500,000 members throughout Oregon and Southwest Washington also supports physicians through cross-specialty collaboration and work-life balance. Together, our engaging practice allows our members—from the people we treat to the practitioners we employ—to live longer, healthier, happier lives.

OUTPATIENT & INPATIENT PSYCHIATRIST OPPORTUNITIESOur Department of Mental Health has a multi-disciplinary staff of over 130 mental health professionals and offers adult and child/adolescent outpatient treatment, intensive outpatient therapy and group therapies, as well as a 24-hour hospital-based crisis program and a residential treatment facility located at our Sunnyside Medical Center in Portland, Oregon.

• Adult Outpatient Psychiatrist opportunities are available throughout the region to provide direct clinical work with outpatients. Must have experience in medication consultations and crisis intervention. Some openings are in Longview-Kelso, WA, which is located 45 miles north of Portland on the Columbia River and is noted as one of the most livable small cities in America. We also have a full-time opening in Salem, OR, a diverse, family-friendly city with charming neighborhoods, close-knit communities and affordable housing.

• Residential Treatment Unit/Consultation Liaison Psychiatrists: Our new, state-of-the-art residential treatment unit specializing in trauma informed care seeks Psychiatrists. Our center features medical management services, skill building groups and individual therapy. Our Residential Unit Psychiatrists also provide consultation liaison services to Kaiser Permanente's Sunnyside Medical Center Emergency Room and inpatient units.

• Child Psychiatrist: Our Portland location currently has a full-time opening.

We offer a competitive salary and benefit package which includes a generous retirement program, professional liability coverage and more. To apply, please visit our Web site at: http://physiciancareers.kp.org/nw/ and click on Career Opportuni-ties. You may also email your CV to Laura Russell: Laura.A.Russell@kp.org. For more information please call (800) 813-3762. No J1 opportunities. We are an equal opportunity employer and value diversity within our organization.

Help Build a Gateway for Better Health

At Northwest Permanente, P.C., we want every patient we see to receive the medical care they need to live long and thrive.

Northwest Permanente, P.C.,Physicians and Surgeons

(Continued on page 5)

4

Executive Council HighlightsAugust 21, 2014 – Tualatin

The Executive Council discussed possible bylaw changes during this meeting, mostly updating language to match model bylaws from the American Psychiatric Association. Among the more significant changes being proposed is increasing membership on the executive council. The Council decided to review the proposed changes in October, and refer the changes to a general membership vote.

Lee Shershow, MD, provided a preview of the upcoming fall meeting in Ashland. Attendance and revenue are both up from last year.

September 18, 2014 – AshlandThe September meeting is held in conjunction with the fall

conference in Ashland. A quorum was not present; Executive Council members had a work session to discuss issues, but did not vote on any issues.

A possible legislative grant from the American Psychiatric Association was discussed, to enhance lobbying and government relations.

A request from past president Candace McKanna, MD, was outlined regarding genetic assay for antidepressants. The Council will review the materials and membership input will be sought.

President Annette Matthews, MD, reminded members that October’s meeting will be spent reviewing bylaws revisions, and the budget will be handled in November.

October 16, 2014 – TualatinBylaws were reviewed by the Executive Council at this

meeting. The goal was to align the bylaws to the American Psychiatric Association’s model bylaws. Some of the more significant changes included a new position on the Council for any member who is elected to a national APA post, elimination of the two regional councilor positions, adding a second resident-fellow voting position so that both Good Samaritan and OHSU have voting positions, and reinstituting a policy that only allows a member to hold one elected position.

The council also reviewed budget and attendance numbers from the fall meeting. There were 189 total attendees in Ashland, not including approximately 60 attendees for the DSM-5 pre-conference. In comparison, the 2013 conference had 154 attendees. The conference brought in approximately $14,000 in net revenue, much of which will be able to go towards replenishing the organization’s legal fund and reserve fund.

• •

• • •

other clinical worlds. Finally, a big thank you to the program committee and its

chair, Lee Shershow, for all their hard work and thoughtfulness in putting our fall and winter conferences together. If you have comments or ideas for future conferences, I am sure he would love to hear from you. Also kudos to Patrick Sieng, our Executive Director; there are a thousand moving parts to a meeting like this, and he did a fantastic job. Hopefully we will see you next year, same time, same place for the 2015 fall conference, and also at our next (winter) conference in Portland, February 27-28, 2015 at the DoubleTree by Hilton.

President’s message(Continued from page 1)

SAVE THE DATE

2015 Winter ConferenceFeb. 27-28

5

HHP Portland is designed to reduce repeat emergency room visits, reduce re-injury, reduce retaliation, reduce PTSD, and promote healing among young males of color who have suffered a penetrating trauma.

Why intervene at the level of the hospital? Studies in 23 major cities have demonstrated the effectiveness of reducing youth violence by intervening in this way. These studies indicate that 44% of young people hospitalized for violence return with another violent injury within 5 years, and 20% of them eventually die by violence.

HHP Portland meets the triple aims outlined by Accountable and Coordinated Care Organizations (ACO’s and CCO’s) by reducing healthcare costs, improving the quality of care and working with specific underserved populations. The HHP model has been presented to Governor Kitzhaber, who wants to see this program expand to other emergency departments across the state, saying that HHP “could save untold millions.” A five-minute OPB report on this topic is available online at:

http://www.opb.org/news/article/counseling-gang-members-just-after-theyve-been-shot/

Oregon outcome statisticsTotal number of clients referred to HHP from June 2013 to June 2014: 29Repeat emergency room visits in one year: 0 out of 29Re-injury in one year: 0 out of 29Retaliation in one year: 0 out of 29Re-arrest in one year: 2 out of 29 (but these re-arrests were for non-violent offenses)Measure of PTSD: PCL scores obtained at the time of injury and at the end show dramatic decrease.

Emergency Departments have traditionally been expert at addressing the physical wounds of trauma, but limited in targeting the psychological wounds. Trauma-informed programs like HHP effectively address the psychological wounds by being mindful of historical and interpersonal trauma in engaging victims and families. HHP is a multi-disciplinary intervention that reduces amygdalar stimulation of trauma, effectively lowering the triggers for aggression. HHP has been able to realize tremendous outcomes by: employing trauma-informed principles and psycho-educational groups and counseling; providing culturally specific care; employing a peer services model; working with the family as a system of care; coordinating care; and treating families and victims with dignity and respect.

HHP Portland has implications for prison reform as well. In Oregon, House Bill 3194 modifies presumptive sentences for certain offenders convicted of identity theft or third degree robbery and eliminates mandatory minimum sentences applicable to certain offenders convicted of drug offenses. The Oregon Department of Corrections (ODOC) has been tasked with decreasing overall prison cost by 5% per inmate per year for the next ten years. ODOC is looking to community providers to render effective services to the offender population in a cost effective, trauma-informed and evidence-based manner. HHP Portland has demonstrated its ability to prevent arrests and re-arrests.

HHP Portland is an effective, trauma-informed, community based model that should be replicated across multiple emergency departments to prevent youth violence.

Alisha Moreland-Capuia, MD is an Assistant Professor of Psychiatry at OHSU. Contact her for further information and references, at morelana@ohsu.edu.

HHP Portland reduces youth violence(Continued from page 3)

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Dramatically improved insurance coverageby Bob George, MD

Historically, the treatment of mental illness has typically involved systems of care which are separated from the rest of medicine, usually involving state hospitals and later outpatient care, through Mental Health clinics, as advocated for by President Kennedy in the early 1960s. Alongside these alternate systems of care, private medical insurance coverage has been limited to a token number of days of inpatient care (usually only 15-30 days lifetime) and possibly covering up to $300-500 annually for outpatient coverage. Individuals who needed more care either paid out-of-pocket if they were affluent, or more typically fell into the state system of care.

The development of effective anti-psychotic medications in the 1950s, the 1960’s discovery that Lithium was useful in managing bipolar disorder, and the development of tricyclic anti-depressants that treat anxiety and depression all increased awareness that some aspects of mental illness could be treated without the need for hospitalization. By the early 1980s in Oregon and a number of progressive states citizens began to demand that health insurance provide coverage for more outpatient treatment. In 1983 the Oregon Legislature negotiated with the health insurance industry to expand access to outpatient MH care with a new outpatient MH benefit of $2000 every two years, paid for largely by reducing the inpatient benefit. Sadly, at that time the OPA’s only interested volunteer legislative advocate, Wayne Pidgeon, MD, was not consulted during this process. The OPA’s lack of influence was unfortunate, and as a result in 1983 OPA President Joe Bloom created a legislative committee, and the OPA hired John McCulley to be our first lobbyist as a means to influence the political process more effectively.

There was also growing pressure nationally to improve coverage for the treatment of mental illness, which had always been significantly less generous than for other types of medical care. In the early 1980s, the American Psychiatric Association

began actively to advocate for ending the traditional disparity in medical coverage for the treatment of mental illness, at least partly as an issue of the civil rights of the mentally ill. This shift in direction for APA represented a formidable task involving the need for much research and education to overcome entrenched stigma related to mental illness and to address the false notion that the provision of non-discriminatory benefits for mental illness would make the cost of health insurance prohibitive. This research came to show that in treating mental illness, not only were the patients benefitted directly, but also the cost of general medical care went down, all without significant change in the overall cost of health care. On the basis of this new data, in 2007 OPA was able to influence passage of cutting edge legislation that requires non-discriminatory coverage for mental illness when MH coverage is offered in a group policy written in Oregon.

In Washington D.C. individual legislators also began to speak out on the need to end discriminatory insurance benefits for the treatment of mental illness. In 2008 two courageous Senators, Paul Wellstone D-Minnesota and Pete Dominici R-New Mexico, were able to pass legislation to end discriminatory health insurance coverage for the mentally ill, but their Wellstone-Dominici Mental Health Parity Bill initially applied only to group insurance policies. For individual health insurance policies, which are commonly over-represented among people with mental illness, the implementation has been delayed for all these years on the basis of technicalities in the interim rules. In the summer of 2013 President Obama assigned a committee to write final rules for full implementation of non-discriminatory coverage. You will be happy to know that the implementation of the 2008 legislation for non-discriminatory mental health insurance coverage, including individual medical plans, became effective July 1, 2014. This is very GOOD NEWS!!

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Enchantment: Natural & Unnatural - Ashland 2014

The panel discussion of the modern Sondheim musical Into the Woods included Dr. Daniel Pollack-Pelzner, Javier Munoz (baker), Kjerstine Rose Anderson (Little Red Riding Hood), Rachel Warren (baker’s wife) and Miriam Laube (witch). The discussion included the central role of community in the production, and questions about the rare but occasional imperative to kill.

Doreen Dodgen-McGee, PsyD from Lake Oswego delivered two vibrant talks related to the psychological impact of modern tech-nology. Facts: a modern 20-year-old will look at a screen 11.5 hours per day, and utilize up to four screens at a time.

Candice Barr and Tom Fauria, PhD got the successful Lane County Physician Wellness Program underway, to give aid to physicians in danger of severe personal failure and possibly suicide.

(Continued on page 10)

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Enchantment: Natural & Unnatural(Continued from page 8)

Dr. Daniel Pollack-Pelzner from Linfield College has become OPPA’s reliable Shakespeare Scholar for our fall conferences. He brought insight, wisdom and plenty of humor to conference at-tendees during his play introductions.

Washington psychiatrist and poet Jed Myers, MD presented alongside his talented poet daughter, Wesleyan student Lily Myers, on poetry and the creative process. Each read some of their original works.

Discussing the dynamic production of Richard III were Dr. Daniel Pollack-Pelzner, Dan Donohue (Richard), David Rovno, MD of California, dramaturg Lydia Garcia, Francelle Dorn (Queen Margaret), and Kate Hurster (Lady Anne).

Jon Emens, MD gave practical and interesting updates to our understanding of dreams and insomnia. Sleep and memory are related; sleep-deprived individuals recall more negative than positive experiences.

Hank Grass, MD spoke about the role that limbic attachment has in psychotherapy.

Mark Kleiman, PhD is professor of public policy at UCLA and spoke about issues related to legalization of marijuana, which he poi-gnantly characterized as a “Whole Foods conversation about a Walmart drug.”

Cecile Bassen, MD, a psy-choanalyst from Washing-ton, explored the uncon-scious themes of Into the Woods, such as the conflict between the oedipal good mother and the competi-tive, bad step-mother.

Acclaimed forensic psychia-trist Charles Scott, MD of UC Davis gave two presentations, on assessing malingered amnesia, and distinctions between treatment of psychopaths and antisocial personalities.

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