UAMS Journal Spring 2014 by University of Arkansas for Medical Sciences

RN L

UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES • SPRING 2014

MENTAL ILLNESS & SUBSTANCE ABUSE

Amazing New Results in Prevention and Treatment

ABOUT THIS ISSUE Dear Readers,

Mental illness and substance abuse cause tremendous suffering for patients

and their families.

Further, these brain diseases cause avoidable deaths and are among the

leading causes of disability for our state and nation. They affect all sorts of people Dan Rahn

â&#x20AC;&#x201D; rich and poor, educated and uneducated, as well as those who are otherwise healthy and those with other diseases.

Unfortunately, the causes of these diseases and the treatments of patients

with these diseases are complex with much still unknown.

Twenty years ago, our state had very limited resources to help patients and

their families with mental disorders and substance abuse. Many of our patients G. Richard Smith

UAMS team members are striving every day to prevent, treat and understand these disorders.

required leaving the state for the care that they needed, especially for the most

complex conditions.

Since that time UAMS and many advocates and donors have made extensive commitments to

help the UAMS Psychiatric Research Institute become not only a statewide resource, but a regional and national resource for the diagnosis, treatment and research of these devastating mental illnesses.

With the addition of the Psychiatric Research Institute and the work done by all our colleagues

across all units including our northwest Arkansas campus, UAMS team members are striving every day to prevent, treat and understand these disorders and reduce the burden of these illnesses for our patients and families. We hope you find this issue of the Journal and the work of our dedicated faculty and staff interesting and helpful.

Dan Rahn, M.D. Chancellor, University of Arkansas for Medical Sciences

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G. Richard Smith, M.D. Dean, College of Medicine Vice Chancellor, University of Arkansas for Medical Sciences

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Journal CONTENTS SPRING 2014

EDITOR

Elizabeth Caldwell CREATIVE DIRECTOR

Laurie Shell WRITERS

Ben Boulden Holland Doran Lauren Farabough Nate Hinkel Jon Parham David Robinson Susan Van Dusen

Overview of Mental Health....................................................................................................... 4 Psychiatric Research Institute.................................................................................................. 8 Restructuring Health Care Delivery........................................................................................ 10. Precision Psychiatry............................................................................................................... 12 Advanced Imaging................................................................................................................. 14 Walker Family Clinic................................................................................................................ 16 Addiction Services................................................................................................................. 18 Methamphetamine Research....................................................................................... 20 Interventional Psychiatry......................................................................................................... 21 ECT...............................................................................................................................22 Prescription Monitoring.......................................................................................................... 24.

PHOTOGRAPHER

Children’s Services................................................................................................................. 26

Johnpaul Jones

Teen Suicide Prevention.........................................................................................................30 Women’s Health..................................................................................................................... 32

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CHANCELLOR

Aging and Memory.................................................................................................................36 Psychiatric Nursing.................................................................................................................38

Dan Rahn, M.D.

Social Work Psychotherapy...................................................................................................40

VICE CHANCELLOR FOR COMMUNICATIONS & MARKETING

Psychiatric Research Institute Northwest............................................................................... 42.

Leslie Taylor

Northwest Arkansas Education..............................................................................................44 Arkansas State Hospital.........................................................................................................46 VA Research...........................................................................................................................48 Pew versus Couch.......................................................................................................50

The UAMS Journal is published twice a year by the Office of Communications & Marketing, University of Arkansas for Medical Sciences, 4301 W. Markham St. #890, Little Rock, AR 72205.

Sexual Health After Violence.................................................................................................. 51 Depression and Heart Disease.............................................................................................. 52 Mental Health and Minorities..................................................................................................54

Phone: (501) 686-5686 Fax: (501) 686-6020

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OVERVIEW

MENTAL HEALTH IN ARKANSAS 

Access, Societal Costs and Parity

U.S.

ARKANSAS

By Elizabeth Caldwell

12.5% 10.7% of population with frequent mental distress

of people who commit suicide have a diagnosable mental disorder

MENTAL DISORDERS are common throughout Arkansas, the United States and the world. They affect people of any age, race or religion, according to the National Alliance on Mental Illness (NAMI). In Arkansas, 12.5 percent of the population reported having frequent mental distress in 2010 compared to 10.7 nationally, according to the Centers for Disease Control and Prevention. The rate was higher for Arkansas women (14 percent) than Arkansas men (11 percent). Arkansans ages 25-34 reported the highest rate at 14.7 percent compared to 6.2 percent of those 75 and above. Mental health professionals know these disorders are not caused by poor upbringing, personal weakness, or lack of character, but are biological medical conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others and ability to function. In the United States, about 26.2 percent of those ages 18 and older have a diagnosable mental disorder, though a much smaller number — about 6 percent of the total population — has a serious mental illness, according to the National Institute on Mental Health (NIMH). Depression is the leading cause of disability for adults, beating out heart disease, cancer and stroke. The NIMH says more than 90 percent of people who commit suicide have a diagnosable mental disorder. In 2010, the latest statistics www.uamshealth

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available, Arkansas’s suicide rate was 15.3 per 100,000 people, ranking high among southern states, according to the American Foundation for Suicide Prevention. Some other statistics from the NIMH: Major depressive disorder affects about 14.8 million, or 6.7 percent of American adults. It is more prevalent in women than men. Chronic, mild depression affects about 3.3 million, or 1.5 percent of adults. Anxiety disorders, which include panic, obsessive-compulsive, post-traumatic stress and generalized anxiety disorders, as well as phobias, affect about 40 million or 18.1 percent of adults. Bipolar disorder affects about 5.7 million, or 2.6 percent of adults, while about 2.4 million, or 1.1 percent of adults, have schizophrenia.

Insufficient Access While many disorders can be treated, help is not always available for many reasons, said Justin Hunt, M.D., an assistant professor of psychiatry in the UAMS College of Medicine, who has completed a prestigious Robert Wood Johnson fellowship in health policy at the University of Michigan. Besides there being a shortage of mental health professionals nationwide, they are not distributed evenly throughout the country, with » UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

15.3

Arkansas' suicide rate per 100,000

in Arkansas adults doesn't have health insurance

Telemedicine is a way to reach more people with fewer resources 6

many psychiatrists and psychologists often being concentrated on the urban East and West Coasts. The ones who do practice in Arkansas are located mainly in the urban areas, particularly Little Rock, leaving the rural parts of the state largely without access. “It’s really based on geography,” Hunt said. ”We have a significant shortage in many rural regions.” Money is another reason, he said. One in four Arkansas adults doesn’t have health insurance, and not all policies have covered mental health well. Many policies have high deductibles. With many private insurance plans paying less for services and requiring increased regulation, some psychiatrists and psychologists have gone to reimbursement on a cash basis, he said. “You can imagine how this has a negative effect on access for folks who don’t have cash laying around to spend on mental distress.” Geography also plays a part in who seeks mental health services. There is more of a stigma associated with mental illness in the South as well as a tendency to think it may be a spiritual or moral problem. www.uamshealth

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“People often tend to turn to spiritual support, which is wonderful and can be a very a productive thing when it comes to mental health, but church can’t resolve an acute psychotic or manic episode,” Hunt said. With a shortage of psychiatrists, psychologists and licensed mental health professionals, telemedicine is a way to reach more people with fewer resources. For instance, Hunt holds a VA telemental health clinic in Russellville once a week from his North Little Rock office an hour away, and UAMS hopes to develop more telemental health services to the underserved civilian population in rural areas. “It’s just as good as face to face in a lot of ways and data support this,” Hunt said. “It represents a clear strategic approach to serve people in rural areas.”

Societal Costs of Mental Illness The cost of mental illness is borne by society as well as the individual. The absence of sufficient mental health infrastructure leads to more homelessness and incarceration, Hunt said. With UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

the crusade in the 1960s and 1970s to close mental institutions and move toward community mental health services, a lot of people with chronic mental illness fell through the cracks. Community mental health services were underfunded and thus ineffective in handling all needs. “The jails and the streets have become our de facto inpatient mental health institutions,” Hunt said. Another mental health social policy issue starts long before adulthood. Children living in neighborhoods with chronic violence or in a home highly disrupted by abuse or neglect often have increased stress responses and a decreased ability to manage stress later in life. Brain-based neuroscience has shown the development of the cortex is often different than for someone raised in a loving, supportive household, he said, and later decision-making and impulse control can be negatively affected. “We know that early childhood trauma has a huge impact on someone’s lifelong trajectory for mental illness,” Hunt said.

as becoming suicidal and ending up in the emergency room,” Hunt said.

Children and Adolescents While Arkansas has some tough problems to deal with concerning the adult mentally ill, the state has made significant progress in treating children and adolescents, Hunt said. A significant portion of the state’s $4 billion to $5 billion Medicaid budget goes to treating children and adolescents with mental health conditions from attention deficit hyperactivity disorder to depression to anxiety. “Arkansas has done a good job of covering its children and adolescents through Medicaid and the State Children’s Health Insurance Program,” Hunt said. “And, the state is now moving forward with behavioral system reforms that will ensure a more coordinated system for both children and adults.” ❖

Childhood trauma has a huge impact on someone’s lifelong trajectory for mental illness

Mental Health Parity With the Mental Health Parity and Addiction Equity Act of 2008, health insurance plans must provide the same or equal benefits for certain mental health conditions that it offers for physical conditions and at the same copayments, deductibles and maximum lifetime benefits. While this gives patients more accessibility to insurance for mental health, it doesn’t fix the problem of not having enough providers accepting insurance, Hunt said. Also, some policies have pretty significant deductibles that can still present a barrier to people with low incomes. “We are concerned people won’t want to spend their cash on the front end for mental health unless something serious happens, such UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

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Pedro Delgado, M.D., leads the UAMS Psychiatric Research Institute

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PSYCHIATRIC RESEARCH INSTITUTE

Pedro Delgado Leads Psychiatric Program 

By Elizabeth Caldwell

IN MEDICAL SCHOOL, Pedro Delgado found himself drawn to the brain. Deciding between neurology, neurosurgery and psychiatry, he chose the path that focused on emotional and cognitive brain function over motor pathways or technically oriented surgical skills. As the new director of the UAMS Psychiatric Research Institute, Delgado is thrilled that the facility has its own Brain Imaging Research Center. One of the few in the nation physically located within a psychiatric department, it allows researchers to delve into the inner workings of the brain. “The resources here are just outstanding. The facility is probably the best in the country, and the caliber of the faculty, staff and trainees is equally impressive,” he said of the institute that opened in December 2008 and integrates research and education with inpatient and outpatient care. Delgado had heard of the institute and its founding director, G. Richard Smith, M.D., long before he thought of moving to Arkansas to take Smith’s place as director and Marie Wilson Howells Professor and chair of the Department of Psychiatry in the UAMS College of Medicine.

He said Smith’s ability to spearhead the creation of the institute is admired throughout academic circles. “It’s the most beautiful, well-developed and laid-out psychiatry space that’s out there. “ When Smith left the institute to become UAMS College of Medicine dean in 2013, Delgado knew he had a rare opportunity. He left his position as professor and chairman of the University of Texas Health Science Center in San Antonio’s Department of Psychiatry where he had been since 2005 and began at UAMS on April 1. Delgado was born in Cuba, the son of a family medicine physician. His family immigrated to the United States in the early 1960s when he was 5. The family settled in Vicksburg, Miss., where his father completed another family medicine residency to be able to practice in the United States. The family eventually moved to Houston where his father built a private practice. His two brothers are family physicians; his three sisters are in the arts. Delgado was on a backpacking vacation through Europe in 1979 when he met his future wife, Sandy, who was on vacation with a girlfriend. “I saw this cute South African girl, and that was that,” Delgado

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said. They decided it was more than a summer romance. She came to Houston for a month, then returned home. A few months later, the freshman medical student wrote her father asking permission for them to marry. The couple has two boys and a girl — Chris, 29, who works in physical theatre in New York; Heather, 26, who lives in Colorado and is finishing her training in occupational therapy in San Antonio; and Nicholas, 22, who is in California earning a master’s degree in early childhood education. Delgado is impressed with UAMS’ broad-based training programs, integrated clinical programs, and research. He sees the opportunity for the research “to match the potential of the facility, the people and the resources.” The development program has engaged the community for strong support, while the partnerships with the VA, the State Hospital and Arkansas Children’s Hospital provide a level of integration that other programs only dream of. “Maybe 10 places in the country have any kind of integration that approaches this. I feel tremendously fortunate to have been selected.” ❖

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“It’s the most beautiful, well-developed and laid-out psychiatry space that’s out there.”

HEALTH CARE ISSUES

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SERVICE LINES 

Restructuring Health Care Delivery

By Elizabeth Caldwell

AS A HEALTH CARE SYSTEM that includes outpatient clinics, inpatient care and emergency services, UAMS is in a unique position to begin moving toward a new kind of health care delivery — one that centers around the patients’ and families’ needs to bring better care at a lower cost. UAMS is leading the way in restructuring its health care delivery system by developing service lines in which the outpatient clinics and hospital create a strategic plan to care for a patient through a continuum of care. The first service line is behavioral health care delivered through the UAMS Psychiatric Research Institute staffed by the College of Medicine’s Department of Psychiatry. “The service line will bring everyone together under a common umbrella of leadership to focus on the main strategic missions of the institute,” said Justin Hunt, M.D., an assistant professor of psychiatry in the UAMS College of Medicine who is helping develop the service line. Expected to begin this year, the service line will align staff and resources under the service line leader, who will be responsible for utilizing staff in the most efficient way possible while giving patients the care they need. For instance, a patient being discharged from the hospital would be transitioned to outpatient care so that he doesn’t end up in crisis and require re-admission. Since inpatient care is expensive, keeping a patient stable in an outpatient setting would save costs. Those savings would be used to supplement clinical research and educating health professionals. “It’s all about efficiency, how we can provide quality care at a lower cost,” said Roxane Townsend, M.D., UAMS Medical Center CEO and vice chancellor for clinical programs. UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

This is also in line with the state’s payment improvement initiative in which the traditional “fee for service” payment system is gradually being replaced with one called “episodes of care.” This requires the provider to be more efficient, such as not duplicating tests and following up to make sure patients are taking medications. If the provider can deliver quality care at a lower cost, the provider shares in the savings. One of the first episodes of care under the state initiative is attention deficit hyperactivity disorder (ADHD). The state’s Medicaid program for lowincome or disabled patients hopes care will be better coordinated, have better quality and save money. For example, sometimes children with this diagnosis are prescribed multiple medications. The service line would strive to coordinate their medications, helping the child and saving the state money, Townsend said. The state’s plan to create behavioral health homes should help patients who have chronic mental illnesses by providing intensive management. Under this model, patients are provided a care coordinator to ensure early intervention to prevent crisis situations, prevent gaps in treatment that could lead to more expensive inpatient services, and coordinate family and community support. Also, the service line model will help physicians and the hospital work more in sync. In the past, the Department of Psychiatry and the institute had separate advisory committees or counsels. Combining these to focus on a common strategy should lower costs and allow the mental health service line to be better positioned for a future focus on population health management. “When you have a clear strategic initiative and structured collaboration, you avoid all kinds of waste,” Hunt said. ❖ www.uamshealth

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“The service line will bring everyone together under a common umbrella of leadership.”

PRECISION PSYCHIATRY

Genetic Testing is Mapping Better Mental Health Treatment 

By Nate Hinkel

Using a person’s genetic profile to tailor treatment is the future of medicine.

WITH AN ARRAY of custom-made products to accommodate almost any need, why do so many patients waste so much time and money test-driving medications that don’t work for them? Experts at UAMS are on the leading edge nationally of finding a way to offer patients the exact medication at the right dosage that is genetically determined to best fit them. Jeffrey Clothier, M.D., vice chair of the College of Medicine’s Department of Psychiatry and medical director of the UAMS Psychiatric Research Institute, said that using a person’s genetic profile to tailor treatment is the future of medicine. “In the next decade or so we will be able to map a person’s complete genetic makeup. That will help patients determine not only their risk for certain diseases, but also pinpoint which medications will work best for them,” he said. “We are already swiftly moving toward seeing those benefits in the mental health field.” G. Bradley Schaefer, M.D., chief of the UAMS Division of Genetics, said a common scenario when someone is diagnosed with depression is to be prescribed one of dozens of selective serotonin reuptake inhibitors (SSRI) such as Prozac or Zoloft that traditionally treat the condition. “For some people it works and for some people it doesn’t,” he said. “That’s when the ‘dance of the thousand SSRIs’ begins,” in which patients try a www.uamshealth

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medication for several months only to find it isn’t working, then spend several weeks being weaned off so they can try another one. “Suddenly you see four or five years of time, enormous patient suffering, and all that money wasted on essentially test-driving medications to find the right fit for a patient,” Schaefer said. “We can be smarter and do a lot better than that.” And they are. Schaefer and Clothier, along with Jennifer Hunt, M.D., chair of the UAMS Department of Pathology, and a team of researchers are on the verge of developing a first-of-its-kind clinical genetic test they hope to begin offering patients this year. This technology will utilize next generation genome techniques that allow the assessment of a large numbers of genes. This helps scientists learn a person’s risk of developing different diseases or even predict genetically predisposed behaviors. Among those genes being developed on this panel at UAMS are ones that will give scientists specific insights pertaining to mental health, such as suicide risk. “The results of this test are essentially the road map that will direct us toward a better understanding of a patient’s diagnosis and the ability to predict various other medical conditions,” Clothier said. “It also will help us identify what medication would best suit a particular patient.” ❖ UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

G. Bradley Schaefer, M.D., says patients shouldn’t have to “test-drive” medications.

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ADVANCED IMAGING

Brain MRIs Show How Treatment Works 

By Katrina Dupins

“We look at how their brains changed before and after treatment.”

THE CHANGES in the teenage girl’s brain were clearly evident in the brain scan. One MRI was taken before being treated for trauma resulting from sexual abuse, the other after receiving trauma-focused cognitive behavioral therapy. The images, taken by a 3 Tesla functional magnetic imaging resonance system (fMRI), are allowing Joshua Cisler, Ph.D., a UAMS assistant professor of psychiatry, to help target treatment for such adolescents. Cisler’s work is made possible through the Helen L. Porter and James T. Dyke Brain Imaging Research Center at UAMS, the only center in the state — and one of the few in the nation — dedicated to brain imaging research. The 3 Tesla fMRI has twice the power of standard MRIs, allowing researchers to see more clearly the inner workings of the brain. Part of UAMS’ Psychiatric Research Institute, the Brain Imaging Research Center began five years ago under founding director Clint Kilts, Ph.D., a professor in the Department of Psychiatry and Behavioral Sciences in the College of Medicine. “I like to build things,” Kilts said. He started by building manpower, choosing faculty and staff who would be able to focus on their areas of expertise. “Imaging science is a team sport. No one person in the center does all of anything.” The center also had the challenge of establishing an identity, something Kilts said was necessary to be a successful imaging center. The center’s focus is threefold: addiction, trauma/anxiety and individual variation. In 2012, Cisler received a $405,000 grant from the National Institutes of Health (NIH) National Institute of Mental Health to study adolescent girls www.uamshealth

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experiencing trauma related to physical or sexual assault. “We are giving them the best treatment that we have,” Cisler said. “But we know that only twothirds of the girls will get better as a result of the treatment.” The study will help clinicians understand how the treatment works, for whom it will work and for whom it will not work. UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Joshua Cisler, Ph.D., uses brain imaging to study changes in patients receiving trauma therapy.

“For those who are getting better, we look at how their brains changed before and after treatment.” For those who didn’t respond, researchers will look at the activity in the brain and focus on what they need to target to get results. Another plus to the research is it allows clinicians to provide the best evidence-based treatment to an at-risk population for free. They are now halfway through data collections in the two-year study.

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The center also is in the final stages of the approval process for another NIH research grant. Researchers will look at three risk factors biologically represented in the brain that may lead to drug dependency. The study will encompass all three focal areas of the center, something that is important to Kilts because it allows researchers to take full advantage of the imaging center’s resources. ❖ www.uamshealth

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WALKER FAMILY CLINIC

Outpatient Treatment Includes Trauma Care 

By Katrina Dupins

A PROPER DIAGNOSIS is key to treating any ailment, and in mental health it’s no different. The Walker Family Clinic, the outpatient arm of UAMS’ Psychiatric Research Institute, provides therapy for a host of mental health disorders, but the one thing common to all treatment is where it starts — with a rigorous assessment. Psychiatrists, psychologists and social workers take a medical history and evaluate the patient’s symptoms. They determine with the patient’s primary care physician and psychiatrist whether he should be cared for at the Walker Clinic or a community health center. 16

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For example, the Walker Clinic treats many disorders but has a focus on trauma, mood disorders, women’s health, and child and adolescent psychiatry. If the patient is a good fit for any of these services, the team devises a treatment plan best suited for the individual. “Through the assessment, we look closely at what mental and social issues may contribute to the patient’s condition,” said Betty Everett, Ph.D., co-director of the clinic’s trauma program and an assistant professor in the Department of Psychiatry. “That can include talking with family members, UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Betty Everett, Ph.D., counsels a patient in the outpatient Walker Family Clinic.

school personnel and other health care providers. With a team approach, we’re able to generate a more complete picture of what level of intervention we should take.” Ricardo Caceda, M.D., Ph.D., and Jeffrey Clothier, M.D., lead the mood disorder program. Mood disorders include depression and bipolar disorder. In the trauma program, a multidisciplinary approach is used to treat patients with posttraumatic stress disorder (PTSD). These adults have a long history of abuse in childhood and continue to have psychiatric symptoms. UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

“We want to provide comprehensive treatment related to trauma including individual and group therapy, medications, and engaging patients in research efforts,” said Erick Messias, M.D., Ph.D., clinic medical director. Joshua Cisler, Ph.D., is a clinician and researcher with the clinic. “Through multidisciplinary collaboration and systematic research, I’m optimistic that treatments will get better,” he said. For example, Cisler is investigating how treatments for PTSD, such as prolonged exposure, change brain function in order to increase comfort with the painful trauma memory. Since it is not possible to erase the memory, evidence-based treatments, such as prolonged exposure, help the patient cope with trauma memories so they aren’t debilitating. “When something triggers a painful memory, there is a lot anxiety, pain and anger,” he said. In one imaging study, he had patients write a narrative of the traumatic event. The patient saw and heard the account five times for three minutes each. Then an advanced imaging system was used to see how the therapy approach makes changes in the brain. By the end of the 15 minutes, the images showed that two neighboring parts of the brain, the hippocampus that helps process memory and context and the amygdala that processes emotion, were communicating with one another. By contrast, the first time the patient heard the narrative, the two parts of the brain were not communicating at all. “We saw the brain change how it processed the information,” Cisler said. “The patient is able to think about the event without feeling uncomfortable. This helps us understand how our treatments for trauma survivors work, and the results are encouraging because they suggest that our brains can recover with the right treatment.” ❖ www.uamshealth

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“We want to provide comprehensive treatment related to trauma.”

ADDICTION SERVICES

Center for Addiction Services and Treatment Encourages Recovery 

By Ben Boulden

LEIGH ANN JONES began methamphetamine and finally,

“I haven’t thought of using anything since going to the center. My life has gotten unbelievably better.”

her journey into addiction when she was 13. Her journey ended more than 25 years later at the Center for Addiction Services and Treatment in the UAMS Psychiatric Research Institute. “I haven’t thought of using anything since going to the center,” Jones said. “My life has gotten unbelievably better. I got my driver’s license back. I’m working, and I’m just a different person than who I was.” Although she also was alcohol dependent, her substance abuse began with opiates — oxycontin, Percocet and hydrocodone. She is not alone. “Probably the biggest problem right now is addiction to prescription drugs and abuse of them,” said Michael Mancino, M.D., program director of the Center for Addiction Services and Treatment. He said the most common addictions the center sees are for opiates, then stimulants like www.uamshealth

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benzodiazepines. Prescription drug abuse is most common in rural states like Arkansas. The center now has about 200 patients in treatment. Jones, who also has bipolar disorder, came to the institute seeking treatment for depression. She had sought treatment for it before but never told anyone about her substance abuse. This time she was at her lowest point, and finally told a clinician, who suggested she try methadone. “I didn’t think it would work, but it did,” Jones said. “Suddenly, I wasn’t craving it. Before the treatment, every day I would wake up thinking about how I would get high that day. Those feelings were gone. It was amazing.” About 10 percent of the general population has problems with an addiction. There is no common psychological trauma or set of psychological causes underlying addiction, Mancino said. “For whatever reason, that 10 » UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Leigh Ann Jones (left) received addiction treatment at UAMS and now sponsors others struggling with addiction.

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percent has a different response when they put alcohol or methamphetamine or cocaine or opiates into their brain and that leads them often to have a very positive experience,” he said. “When they have that experience, they want to use it again. Before they know it, they look up, and they’re addicted to the substance.” Typically, an addicted person fears withdrawal should they cease using. They want help with that first and usually have only a slight interest in counseling. Counseling however is a much bigger part of the therapy that

the center provides. Under an older model of treatment, some facilities treated chemical dependence, and other facilities provided counseling services, but the center does both in parallel, Mancino said. “The methadone took away the withdrawal and cravings, but I wouldn’t have stayed clean without the counseling and support groups,” Jones said. “The counseling is so important. You are so weak at the beginning, and they help you through it.” Jones also attends support groups outside the center and now sponsors a younger woman

who is struggling with addiction. The center also prescribes Suboxone to patients addicted to opiates. Because of federal drug laws and controls, methadone patients must pick up their doses daily, but they are allowed to have a month’s supply of Suboxone. The center has many success stories. Jones’ story isn’t unique, but it’s special to her. “I was ready,” she said. “I was ready to know my children. I’m 42, and now my kids and I don’t go a day without seeing each other. I could talk about it for forever.” ❖

Methamphetamine Research and Treatment The Center for Addiction Research in the Psychiatric Research Institute is working to find a drug treatment that will help people addicted to methamphetamine get free of their dependence on the drug. People participating in research at the center are often placed in a local residential facility first to help them become abstinent and start taking study medication. Then participants are discharged and continue to participate at the center for 10-12 weeks, receiving outpatient individual cognitive therapy during this time. Alison Oliveto, Ph.D., professor and vice chair for research in the Department of Psychiatry and Behavioral

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Sciences in the UAMS College of Medicine and a senior scientist at the center, said three studies are under way — one for methamphetamine, one for cocaine and one for both. Researchers are looking for a drug treatment that will assist stimulant-dependent people in their recovery and help prevent relapse. “I see a drug as a way of increasing the therapeutic window,” she said. “I do not see it as a magic bullet but as a tool to enhance the recovery process.” Two recently completed studies examined whether the drug sertraline prevented relapse in cocaine-dependent patients. These studies showed that those receiving

sertraline were much less likely to relapse than those receiving a placebo, and that sertraline was particularly effective in improving outcomes for those with alcohol dependence, which is co-occurring in more than half of cocaine users. In another effort to address meth addiction, UAMS researchers Michael Owens, Ph.D., Brooks Gentry, M.D., and Misty Stevens, Ph.D., are conducting clinical trials of antibody-based medications expected to significantly reduce or prevent the euphoric rush that drug users crave. If approved, the antibody would be part of a user’s treatment program along with counseling and possibly other medications. — Ben Boulden

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INTERVENTIONAL PSYCHIATRY 

Addressing Resistant Disorders

By David Robinson

When traditional medications for resistant mental disorders fail, doctors may turn to novel therapies that fall under a relatively new realm of medicine known as interventional psychiatry. This includes electroconvulsive therapy (ECT), ketamine infusions, repetitive transcranial magnetic stimulation (rTMS), and deep-brain stimulation. » UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

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“Interventional psychiatry is a new way of addressing more severe cases.”

“Interventional psychiatry is a new way of addressing more severe cases,” said Jeffery Clothier, M.D., a psychiatrist and professor in the UAMS College of Medicine Department of Psychiatry. Severe and resistant depression is the mosttreated disorder using interventional psychiatry methods, and ECT is the most used of these treatments. ECT, also used for catatonia, schizophrenia and mania, is safe, effective and it is covered by insurance. Formerly known as electroshock, ECT induces seizures by sending electrical current through two electrodes. The brain is “reset,” making it more responsive to medications, said Lou Ann Eads, M.D., who directs UAMS’ ECT service. “ECT is the heart and soul of interventional psychiatry,” Clothier said. Patients who don’t respond to ECT may be offered ketamine, an FDA-approved anesthetic that has shown to be effective at treating depression. Clothier said patients respond to ketamine about 80 percent of the time, but it is often not covered by insurance “We use it to break the depression and then have patients on a more definitive medication,”

Clothier said. Repetitive transcranial magnetic stimulation (rTMS) is being studied by UAMS’ Erick Messias, M.D., Ph.D., M.P.H. During the procedure, a large magnet sends pulses through the skull, and depending on the frequency of pulses, may excite or inhibit the activity of the brain’s neurons. Messias hopes rTMS can be used to help people with auditory hallucinations — hearing voices — which usually is associated with schizophrenia. “Schizophrenia can be a devastating disease and our medications are limited,” said Messias, medical director for the Walker Family Clinic at the UAMS Psychiatric Research Institute. “They suffer tremendously.” Patients may hear commanding voices that tell them to hurt themselves, that they are no good and they should die, he said. Messias notes that his pilot study evolved from research in the laboratory of UAMS’ Edgar Garcia-Rill, M.D., and the UAMS Center for Translational Neuroscience. UAMS’ Erika Petersen, M.D., a neurosurgeon, is studying the potential of deep brain stimulation in helping patients with resistant mental illnesses. ❖

Patients Say ECT Saved Their Lives Bob Scroggin thought of the movie “One Flew Over the Cuckoo’s Nest” when his psychiatrist suggested electroconvulsive therapy (ECT) for his severe depression, but he barely flinched. “I was ready to try anything,” said Scroggin, 69, of Conway. “I was that bad off.” Although ECT – formerly known as electroshock – has been significantly improved since that 1975 movie starring Jack Nicholson, the idea initially terrified Leigh Phillips, of Searcy. But medications hadn’t helped her anxiety, panic attacks and depression. “I was so sick I couldn’t even go to Wal-Mart,” said Phillips, who was a licensed practical nurse for 33 years. “I was terrified of people.” After its introduction in 1938, ECT was widely

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adopted by the 1950s, then abandoned by many providers as new medications became available, said Lou Ann Eads, M.D., a psychiatrist who oversees the ECT service at the UAMS Psychiatric Research Institute. But all patients did not respond to medication, and as ECT delivery was improved, it became a standard treatment, providing relief from psychiatric illnesses, primarily resistant and severe depression. During ECT, seizures are induced by sending electrical current through two electrodes. During the roughly 30-second seizures, there’s a massive release of neurotransmitters, Eads said, helping “reset” the brain and making it more responsive to medications.

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Bob Scroggins (right) says ECT, under the direction of Lou Ann Eads, M.D., helped him recover from depression.

“People get better with ECT. They really get better and it improves their quality of life.”

Patients sleep through the procedure while under anesthesia, and a muscle relaxer prevents physical harm from the seizures. Eads also takes a conservative approach to minimize risks, primarily memory loss. UAMS is one of only two ECT sites in Arkansas and the only site that treats pregnant women. It is also the only site adjacent to a comprehensive medical facility, important for patients with other serious medical conditions. ECT helps patients 75-80 percent of the time, Eads said. “People get better with ECT. They really get better and it improves their quality of life.” Scroggin and Phillips say that’s an understatement. After Phillips initially rejected the idea in

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September 2012, she talked to her husband and Eads and concluded that she didn’t have anything to lose; and she trusted Eads. After a series of ECT treatments she said she feels “100 percent better” with a new outlook on life. She’s traveled to California to see four of her six grandchildren. “It’s just wonderful to be well again.” At his worst, two years ago, Scroggin was suicidal and left his public relations job. His psychiatrist mentioned that UAMS offered ECT. Scroggin quickly scheduled an appointment. Today Scroggin volunteers and has several hobbies, including wood working and motorcycle riding. “It feels good to live,” he said. “UAMS saved my life.” — David Robinson

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PRESCRIPTION MONITORING PROGRAM

Tracking Controlled Drug Prescription Use in Arkansas 

By Lauren Farabough

“The prescription monitoring program is one effort to curb drug abuse.”

ARKANSAS HAS A SERIOUS DRUG PROBLEM that started with a prescription pad and a doctor’s signature. Prescription drug abuse has surpassed the use of illicit drugs, and Arkansas ranks first of all states in non-medical use of prescription pain relievers. However, Arkansas pharmacists and other health care providers are now taking a leading role to turn this around. “Prescription drug abuse is tragic and something that doesn’t have to happen. We need to determine what we can do through education and limiting access,” said Stephanie Gardner, Pharm.D., Ed.D., dean of the UAMS College of Pharmacy. In 2011, legislation was passed to establish the Arkansas Prescription Monitoring Program under the direction of the Arkansas Department of Health. Arkansas Drug Director Fran Flener led the initiative. Arkansas was one of the last states in the country to implement such a program. Beginning March 1, 2013, any dispenser of a controlled substance must report the prescription to an online database. Previously, a person could obtain multiple prescriptions for the same substance from different prescribers and get them filled at different pharmacies without any way of pharmacists or prescribers knowing. Now, users of the program have a helpful tool to monitor the use of controlled substances. “We have had good cooperation within the medical community. It is being widely used from pharmacists to physician assistants, advanced practice nurses, dentists and doctors,” said Denise Robertson, P.D., administrator of the prescription monitoring program. More than 9.6 million prescriptions have been www.uamshealth

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submitted. The next goal is to increase its usage. “As a College of Pharmacy, I think we should play a role in trying to decrease prescription drug abuse in Arkansas,” Gardner said. She and pharmacy students helped sign up about 200 pharmacists at Arkansas Pharmacists Association meetings last year. “If these pharmacists use the program every day, just over a month, imagine the impact that would have,” she said. She created and distributed a survey to several hundred health care professionals to determine ways to improve the program. “I’m trying to help get more pharmacists and physicians enrolled and signed up to use the program,” Gardner said. “I’m also interested to see if there’s any way we can help make the system easier to use once they are signed up.” Pharmacy and medical students are being exposed to the program and taught about the dangers of prescription drug addiction. “The prescription monitoring program is one effort to curb drug abuse,” Gardner said. “Education is a huge part of it too, and that’s what we’re about at UAMS.” The database is not intended to make it difficult for people who need the medicines to obtain them. “There is a legitimate need for many people to take these medications,” Robertson said. “The database could help steer people who have started having problems in the right direction.” She said a future initiative is to connect to other states’ databases as well as make sure prescription information is included in patients’ electronic health records. “We’ve had lots of positive feedback with some good success stories from doctors and we expect to hear many more,” Robertson said. ❖ UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Denise Robertson (left), of the Arkansas Department of Health, and Stephanie Gardner, dean of the UAMS College of Pharmacy, work to decrease prescription drug abuse.

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A father and son enjoy playground equipment at the Children’s Diagnostic Unit. www.uamshealth

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CHILDREN’S SERVICES

Inpatient and Outpatient Services Educate Families in Recovery Process 

By Holland Doran

TREATING A CHILD with mental health issues is a family affair at UAMS. Whether the child needs inpatient services or can be treated in an outpatient setting, mental health specialists place an emphasis on involving the whole family. The 10-bed inpatient Children’s Diagnostic Unit at the UAMS Psychiatric Research Institute sees children age 2-12. Patients are referred from across the state by community mental health centers, schools, family members and physicians. Specialists in psychiatry, psychology, social work, speech and language, occupational therapy, nursing and education observe and work with children and families, where an average stay is 28 days. “As part of the patient- and family-centered care that we offer, we allow a parent to room with their children,” said Molly Gathright, M.D., medical director of the unit since it opened in 2009. “We teach the families as well because they are as much of the process as the child.” Diagnosing disorders such as post-traumatic stress, psychosis, anxiety, depression, autism, disruptive behavior, learning, speech and language, and intellectual disability is like putting together a puzzle, Gathright said. “I often tell the families of the children we treat that they brought me pieces to a puzzle, and » UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

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“We teach the families as well because they are as much of the process as the child.”

Counselors trained in trauma care through AR BEST Until five years ago, help in overcoming the trauma of sexual or physical abuse was not always readily available for many Arkansas children. Since that time, a new program has trained more than 900 mental health professionals throughout the state to provide the evidencebased trauma services these children need. Arkansas Building Effective Services for Trauma (called AR BEST) is coordinated by the UAMS Psychiatric Research Institute, which collaborates with community partners to increase the availability of mental health professionals to treat children who have experienced trauma.

AR BEST began in 2009 and has trained health

care workers in 62 of the state’s 75 counties, with more than 1,800 Arkansas children receiving trauma care. The program has helped train counselors affiliated with all 13 Arkansas Child Advocacy Centers (CACs) as well as community mental health centers and other mental health care settings. “The CACs are where children go after there has been an allegation of sexual abuse,” said Teresa Kramer, Ph.D., professor in the UAMS Department of Psychiatry. “They are set up as safe places for children to be interviewed. Through the partnerships with these centers, we can know how many kids are getting into care and how to improve the quality of care.” AR BEST trains mental health professionals in trauma-focused cognitive behavioral therapy for children ages 3 through 18. The training is acquired through three stages: completion of free online training modules, a two-day conference at UAMS led by model co-developer Tony Mannarino, Ph.D., of Pittsburg, and teleconferences with national experts. The program also trains child welfare workers and foster parents, screens and tracks client and family needs, and provides funding to CACs to ensure children and families have access to evidence-based treatment. — Holland Doran

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it’s our job to put the pieces together to create a picture of your child that will give us a better understanding,” she said. The specialists develop a treatment plan for each child using a model called collaborative problem solving. The method focuses on the idea that each child will succeed if they can, not if they want to. “If the kids are not meeting expectations, it’s because they can’t — it’s because they are lacking a set of cognitive skills that are necessary in order for them to function well, such as language processing, emotional regulation or social skills,” said Khiela Holmes, Ph.D., a clinical psychologist on the unit. Before a patient is discharged, specialists meet with anyone within the child’s social sphere for an educational, comprehensive discharge conference. To make sure the child continues with community-based resources, the unit provides follow-up through Psych TLC (Psychiatric Telehealth, Liaison and Consults). Each child is assigned a mental health professional to provide at minimum weekly contact for 90 days and the child’s local health care provider can call the Psychiatric Research Institute 24/7 to consult about their patient. UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

STRIVE Provides Treatment in a School Setting

Psych TLC also allows physicians and advanced practice nurses in Arkansas to consult 24/7 with a child psychiatrist on diagnosing and treating their other patients at no cost to the provider or parents. UAMS’ Child Study Center Outpatient Clinic has been treating children and adolescents since 1969. Located at UAMS affiliate Arkansas Children’s Hospital, the clinic serves more than 1,000 new patients a year. “We have experts in trauma treatment at the Child Study Center,” said Glenn Mesman, Ph.D., a psychologist with the Child Study Center. Patients are referred to the clinic for behavioral, emotional, learning and adjustment difficulties and adjustment delays. Therapists see a range of disorders including ADHD, post-traumatic stress, anxiety, depression, developmental delays, autism, and psychosis, all of which could manifest disruptive behavior disorders that may be characterized by temper tantrums, physical aggression, stealing and other forms of defiance or resistance to authority. Treatment services include cognitive-behavioral therapy; individual and family therapy, behavior management techniques, parent education training, and medication treatment. ❖

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The therapy services provided by UAMS in the North Little Rock School District began in the 1990s as a way to address behavior problems at a time when central Arkansas was known nationwide for its gang violence. As the student’s behavior, grades and coping skills improved, it drew attention. The program became known as STRIVE (Seeking to Reinforce my Identity and Values Everyday), and now works with children in 25 to 30 schools in the North Little Rock, Little Rock and Pulaski County Special school districts as well as the LISA Academy and Head Start Program. Licensed clinical social worker Paula McCarther, STRIVE director, said clinicians get a more comprehensive view of a student’s mental health needs by talking with teachers, parents and others who interact with the student every day. “With STRIVE, we are able to get collaborative information in order to see the true mental picture of a patient,” McCarther said. “It really allows you to treat the whole person instead of getting a onesided perspective from the patient.” STRIVE’s therapists attend to almost 400 students at any one time, averaging 2,000 visits a month. The program offers outpatient therapy to students and their families, interventions, medication management and psychological testing to help students at risk for out-of-home placement or failing academically due to emotional and behavioral problems. STRIVE, part of the UAMS Psychiatric Research Institute’s outpatient program, has decreased the stigma surrounding mental health for children and their parents. Because it’s school based, children who could not afford to get treatment in the community or had transportation challenges are able to get the help they need where it’s seen as part of an educational setting, Brown said. — Holland Doran

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TEEN SUICIDE PREVENTION

Teen Suicide Influenced by Bullying, Drugs, Risky Sex 

By Susan Van Dusen

WHILE A TRAGEDY, teen suicide rarely makes the news. It is most often experienced privately by families and friends who may struggle for years with grief and unanswered questions, including the inevitable, “Why?” Although they may never know the exact answer, a number of risk factors have been proven to increase a young person’s likelihood of suicide. Three of these factors — bullying, drug use and risky sexual behavior — were the focus of a study by Erick Messias, M.D., Ph.D., medical director of the Walker Family Clinic at the UAMS Psychiatric Research Institute. By analyzing Arkansas-specific data collected by the Centers for Disease Control and Prevention (CDC), Messias determined that these three risk factors have a direct correlation with suicidal tendencies in teenagers across the state. “We should not accept that bullying, drug use and risky sexual behavior are part of a normal, healthy teen experience. In fact, they have very negative outcomes,” said Messias, who also holds a master’s degree in public health and is trained as an epidemiologist. The data Messias analyzed was collected in 2011 from about 4,000 Arkansas public high school students as part of the CDC’s national Youth Risk Behavior Survey. Studying the Arkansas-specific numbers is important in understanding what is happening close to home, Messias said, as opposed to depending only on nationwide statistics. Messias found that students who reported being bullied at school had an increased risk of suicidal thoughts, while those who were bullied online had an even greater risk. When bullied in both arenas, the risk increased even more. “Because this is a new phenomenon, we aren’t knowledgeable enough about cyber bullying, we aren’t fully prepared for it and we don’t have much

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experience addressing it. We have a lot of work to do to prevent tragedies after children are cyber bullied,” he said. The second set of risk factors Messias examined included risky sexual behaviors, specifically focusing on children who engaged in sexual activity before age 13 and those who had multiple partners. Both of these behaviors, he said, were accompanied by an increased risk of sadness and suicide attempts. One of the most surprising findings for Messias centered on the fact that 10 percent of Arkansas students reported being forced to have sex. This finding is 2 percent higher than the national average. “We need to understand that forced sex is happening and is clearly the strongest predictor of suicidal behavior among teens,” he said, adding that teens who reported being forced to have sex were 3.5 times more likely to report having attempted suicide. The final factor Messias examined was one widely known to play a part in suicides: drug use. In the CDC’s survey, one third of Arkansas teens reported having used cannabis at least once, and more than 10 percent admitted to using inhalants or abusing prescription drugs. “All of these increase your risk for suicide and depression,” he said. Messias plans to use his findings to further examine if there are geographic areas or demographic groups in the state that most often display these risk factors. Then, education programs, particularly for parents and teachers, can be developed to recognize, address and prevent these risky behaviors. “I know we can’t prevent every bad outcome. But we can work to prevent most of them,” he said. ❖

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“We have a lot of work to do to prevent tragedies after children are cyber bullied.”

Soothing colors and comfortable seating provide space for group therapy as part of women’s services.

WOMEN’S HEALTH

Inpatient Unit Specializes in Women’s Issues 

By Susan Van Dusen

“The security of being among only women provides what I call ‘psychological oxygen.’”

IN MARCH 2013, UAMS did more than open a specialized psychiatric unit. It also ushered in a new era for women’s mental health in Arkansas. Located on the fifth floor of the UAMS Psychiatric Research Institute, the 10-bed unit is the only facility in Arkansas to offer acute inpatient mental health services in a setting exclusively for women. “The security of being among only women provides what I call ‘psychological oxygen’ that isn’t readily available in a group with men,” said Laura Tyler, Ph.D., institute administrator and a licensed professional counselor. The unit is similar in concept to a traditional intensive care unit, Tyler said, except that the patients are experiencing acute psychiatric conditions, rather than physical illnesses or injuries. Women admitted to the unit may be experiencing severe depression, suicidal or homicidal thoughts, psychotic episodes, or other mental illnesses. The average length of stay is five to seven days, after which patients are discharged into the care of a therapist for outpatient treatment. “When you have a setting for women only, everyone has something in common. In our group sessions, we can focus all of our attention

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on issues that affect women, whether it be related to pregnancy, parenting, sexuality, abuse or other areas,” said Zachary Stowe, M.D., medical director of the Women’s Mental Health Program and a nationally known expert in mental health issues affecting pregnant and postpartum women. Stowe treats all pregnant and postpartum women in the unit, while Lou Ann Eads, M.D., and Shona Ray, M.D., see all other patients. With the exception of Stowe and rotating physicians, the unit’s entire team of providers is women.

Focus on Women The idea for the unit came about after the Psychiatric Research Institute opened in 2008 and leaders were looking at ways to address unmet needs in the community. By focusing their efforts on a women’s-only unit, they developed a program to tackle complex mental health issues in a setting unlike traditional psychiatric units. “We are able to give more attention to therapy throughout the day and teach coping skills that will help our patients succeed when they leave the hospital,” said Eads, who also is an assistant professor in the UAMS Department of Psychiatry. A primary focus of the unit is on group »

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“When you have a setting for women only, everyone has something in common.”

sessions designed to help the women develop trust, build relationships and learn from each other as well as from their group leaders. Staff members representing UAMS’ wide range of programs and services lead sessions on all aspects of a woman’s life. “We have group sessions led by dietitians, chaplains, occupational and recreational therapists, nurses and social workers. This environment gives us the freedom to do the therapeutic work that prepares the women to re-enter their everyday lives,” Tyler said. She said the inpatient nursing staff also contributes to the healing, calling them “the lifeblood” of the service. Not only does the unit have a specialized therapeutic focus, it also has a unique aesthetic quality — the walls are lavender, the beds have feminine coverings and original artwork is found in each room. “Creating a homelike environment is important and unique to this facility,” Tyler said, adding that the patients chose the paint color and a quilting guild in Benton handcrafted the quilts that are framed on the walls to serve as headboards. Stowe said that while safety is always the main concern, the decorative elements add a special touch www.uamshealth

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that isn’t found in other psychiatric units. “Our group therapy room is filled with natural light, and we have comfortable seating areas. These are all added benefits that aid in the healing process,” he said.

Expert Care When a women who is pregnant or has recently given birth is admitted for inpatient care, her needs require special consideration that Stowe is distinctly qualified to provide. After encountering his first case of acute onset postpartum psychosis while still in his residency, Stowe has devoted his career to treating women with pregnancy-related mental health conditions, both in the outpatient and inpatient setting. “Dr. Stowe’s band of experience is very wide. He brings decades of experience in working with women and understanding the intricacies of how medications and therapies can improve outcomes during pregnancy and after a woman gives birth,” Tyler said, adding that pregnancy creates a level of complexity to mental health treatment that many doctors are not specially trained to handle. “Physicians genuinely want the mothers and babies to have the best possible treatment, so they UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

often refer to a specialist, such as Dr. Stowe, who is highly trained to understand their unique needs,” Tyler said. Stowe is a professor in the UAMS Departments of Psychiatry, Pediatrics, and Obstetrics and Gynecology. Since UAMS has most of the state’s only boardcertified physicians in maternal-fetal medicine, many women with complicated pregnancies are already referred to the university’s hospital and clinics for treatment. The women’s unit, Stowe said, is a natural outgrowth of the care that UAMS already provides. “We have a unique advantage at UAMS of having all of the departments in place that are pivotal to a successful women’s mental health program, and they are all willing to work together in our patients’ best interest,” Stowe said.

Turning the Tide While each woman admitted to the inpatient unit has unique needs, there is one common thread running through many of their lives: abuse. Whether it’s verbal, physical or sexual in nature, abuse often results in trauma severe enough to warrant inpatient psychiatric treatment. “You would be surprised by how many women have suffered some form of abuse, whether as a child or as an adult. We have the ability here to provide a secure environment for women to start addressing and dealing with these issues,” Eads said. Although Eads admits that doctors don’t have a crystal ball to predict when a patient is ready to re-enter everyday life, she believes that the inpatient unit fills an important gap for women at the most acute stage of mental illness. “We are set up to help women who are struggling with issues that often get swept under the rug. After we get them on appropriate medications and in group therapy sessions, they can start thinking about how to change their lives. This is a safe place to make that possible,” Eads said. ❖ UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Research for Future Generations Zachary Stowe, M.D., knows that he may never see the results of his research efforts. But that isn’t stopping him from creating a resource that will undoubtedly benefit future generations.

The Transgenerational Biorepository, located

at the Arkansas Children’s Hospital Research Institute (ACHRI), is designed to collect and store DNA samples from adults and children that, over time, will yield important information about which populations are more vulnerable to disease and why. “I don’t know what tests will be available years from now, but I do know that if we have DNA samples, we will be able to use them and learn from them,” said Stowe, a professor in the UAMS Departments of Psychiatry, Pediatrics, and Obstetrics and Gynecology. As director of the Women’s Mental Health Program at UAMS, Stowe envisions the biorepository as a source for information on why and when certain women are more prone to develop psychiatric conditions. He also sees the data as vital for other disease-related research, by revealing demographic trends and risk factors in both adults and children.

Stowe, who specializes in mental health for

pregnant and postpartum women, also seeks to enroll all of his patents in research studies to examine the effects of neuropsychiatric illness and pregnancy. One of his research projects looks at the conditions that influence a mother’s ability to bond with her baby.

“We are examining whether the use of street

drugs causes changes in a woman’s brain that prevent her from properly bonding with her baby, and if those changes can be reversed by removing the offending drug,” he said. — Susan Van Dusen

Jeri Hudson of Bates

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AGING AND MEMORY

Memory Gets a Boost at Reynolds Institute on Aging 

By Ben Boulden

“We want to help the patient as well as the whole family.”

EVERY DAY can be a struggle for a person with memory problems. But there’s help at the Walker Memory Center in UAMS’ Donald W. Reynolds Institute on Aging. “Once we have arrived at a diagnosis, we share it with the family members, but we don’t just let them go,” said Jeanne Wei, M.D., Ph.D., the institute’s executive director. “We don’t say ‘you failed the memory test and have dementia, goodbye.’ We want to help the patient as well as the whole family. We look for ways to improve the patient’s function, such as through cognitive development therapy training; how do you maintain, improve, keep going.” Denise Compton, Ph.D., a neuropsychologist at the institute, recounted the story of a patient who was a little younger than typical, and who was having memory problems and behavioral issues that were making her family’s life difficult. A community psychiatrist had offered a diagnosis of mild cognitive impairment. When this patient and patient’s family came to the institute’s Memory Center, they first met with a neurologist Mark Pippenger, M.D., and then with Compton. When Compton performed a neuropsychological evaluation, it showed the patient had progressed from mild cognitive impairment to dementia and needed to quit working. Further testing showed the patient needed to quit driving. The Memory Center’s social work staff assisted in processing disability, financial assistance and access to long-term care insurance. The faculty and staff provided clear explanations of the disease and hands-on suggestions for quality care of the patient at home. www.uamshealth

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Because of the patient’s numerous difficulties, such as weakness and falling, the Memory Center was also able to provide physical therapy and occupational therapy. They provided information to local services and programs for additional assistance, including access to the institute’s Schmieding Caregiver Training Program that provides training to caregivers to allow patients to remain in their home longer. UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Neuropsychologist Denise Compton, Ph.D., (right) helps patients at the Walker Memory Center of the UAMS Institute on Aging.

New innovative methods of assessment are being established to more accurately diagnose each patient. “We are starting to revisit and reexamine the norms,” Wei said. During an evaluation, clinicians look at how well they are functioning day-to-day and whether any memory loss is simply attributable to the normal aging process. Neurologists and neuropsychologists now believe that mild UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

cognitive impairment or mild dementia may be stable in a patient for a few years. “What makes this Memory Center unique is that we treat the whole patient and the whole surrounding environment of the patient,” Wei said. “For instance, if a patient has high blood pressure or diabetes, these conditions are major risk factors for stroke, which will contribute to memory loss, so treat those conditions as well.” ❖ www.uamshealth

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PSYCHIATRIC NURSING

Nurses Training to Meet Mental Health Needs 

By Nate Hinkel

NURSES WITH EDUCATION and training in mental health care are helping meet the needs of patients across Arkansas, and UAMS is providing the necessary resources to make that happen. With a large unmet need for mental health services, especially in the state’s rural areas, the psychiatric-mental health nurse practitioner is vital to ensuring access to services. “The future of health care is demanding a change in the way the system treats mental health, and we are a large part of the solution,” said Sara Jones, Ph.D., the psychiatric mental health specialty coordinator for the UAMS College of Nursing. “There is a great need for more highly trained professionals, especially in the rural areas where health care services are sparse.” The psychiatric-mental health nurse practitioner specialty is one of seven UAMS College of Nursing graduate programs that prepare nurses for specialty practice in advanced nursing roles. Psychiatric advanced practice nurses provide primary mental health care across the state. They are able to assess and diagnose mental illness, manage medication, and provide family and group therapy as well as brief psychotherapy, among many other services. They practice in community mental health clinics, psychiatric inpatient units, hospital emergency departments, prisons and even private practices. “The role of highly trained nurses is truly the future of health care in this state and across the country,” said Lorraine Frazier, Ph.D., R.N., dean of the UAMS College of Nursing. “Mental health is an important area, and there is a significant need to train more psychiatric-mental health nurse 38

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Sara Jones, Ph.D., helps train psychiatric-mental health nurse practitioners at the UAMS College of Nursing.

practitioners to help meet our state’s health care needs.” Patients traditionally rely on their primary care physicians for a referral for psychiatric care. However, a lack of availability and timeliness of an appointment with a psychiatrist can pose a risk to patients in need of care. When psychiatric nurses are in the community, availability and costliness can be vastly improved. As part of their education, psychiatric nurses complete 540 hours of training with a psychiatrist or licensed psychiatric nurse. Jones said it is a growing program that is adding about 10 graduates to the UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

“There is a significant need to train more psychiatric-mental health nurse practitioners.”

workforce each year. “We’re the only program in the state where advanced practice nurses can learn to provide primary mental health care across the entire lifespan.” Many family advanced practice nurses across the state, especially in rural areas, report that they see many patients with psychiatric symptoms and they don’t have many resources for referral, Jones said. The UAMS program allows these nurse practitioners to complete the psychiatricmental health specialty courses and apply for a post-master’s certification in mental health. In UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Arkansas, a psychiatric nurse is authorized to prescribe medications while in a collaborative agreement with a psychiatrist. They can provide most psychiatric medications for depression, anxiety and psychotic disorders. Their practice greatly contributes to meeting the overwhelming need of mental health care across the state. “Other providers all want more psych nurses because there is an extreme need for these services across Arkansas and there just aren’t enough people doing it,” Jones said. ❖

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SOCIAL WORK PSYCHOTHERAPY

UAMS, UALR Center Provides Therapy Training 

By Jon Parham

“Mental health professionals must adapt to changing cultural issues and develop interventions that make sense.”

WHEN LICENSED CLINICAL SOCIAL WORKER Kevin Navin was in graduate school in the 1990s, email was still largely only found on university campuses and pagers were commonplace. Just as technology has changed, so have mental health treatment models, Navin said. Counselors must stay current, not only to provide the best care to clients but also to understand how changing societal factors may require new approaches. These factors make the Psychotherapy Training Center, co-sponsored by the UAMS Psychiatric Research Institute and the University of Arkansas at Little Rock (UALR) School of Social Work, critical — and convenient. “These courses provide a terrific opportunity to go far more in-depth in the material than a one-day continuing education session that might require traveling across the country,” said Navin, a therapist with the Psychiatric Research Institute. “Therapy is a nuanced and challenging process and there is always room to improve my skill set.” Kim Jones, Ph.D., director of the training center and a professor in the UALR School of Social Work, said the five-year-old program grew out of discussions with then-institute director G. Richard Smith, M.D. “We wanted to create a set of courses focused on evidence-based psychotherapy — training not available in Arkansas,” Jones said. The 10-15 week courses include cognitivebehavioral psychotherapy with an emphasis on treating mood, anxiety and personality disorders. Other courses include family therapy, couples www.uamshealth

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therapy, acceptance and commitment therapy, psychodynamic psychotherapy, and dialectical behavior therapy, which can be used for treating personality disorders., Evidence-based means the techniques are rooted in proven therapy approaches backed by data and research. “Patients are coming in more informed than ever before so they want to know the treatment they will receive has been shown effective in other settings,” Jones said. The program capitalizes on the resources of both institutions. UALR provides some of the instructors and the curriculum, the Psychiatric Research Institute offers the space and equipment, along with the one of the main target audiences— its clinicians, residents and fellows. Other participants in the courses include UALR graduate students in social work along with community mental health. The multi-disciplinary nature of the program participants reflects the environment many therapists will practice in, offering another benefit, Jones said. Navin said it gives the courses exciting energy to have experienced clinicians learning alongside graduate students. Navin participated in the couples therapy course and is now attending the course in acceptance and commitment therapy. This model for treatment differs from cognitive behavioral therapy in that rather than teaching patients to control thoughts, feelings or sensations, it embraces awareness, acceptance and understanding. “Mental health professionals must adapt to UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Kevin Navin, a licensed clinical social worker, sits in on a patient session to observe the latest therapy techniques.

changing cultural issues and develop interventions that make sense, which is why it’s important for therapists to know the most current thinking and approaches,” Navin said. “Family systems have changed. It is commonplace for 25-year-olds to live at home and for grandparents to raise grandchildren.” Licensed clinical social worker Karen Miller, UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

who also took the family therapy course added: “Part of the course involved observing the instructors conducting family therapy sessions with consenting new clients. It was incredibly informative to watch them skillfully model the skills that I’d previously just read about. The difference in my practice was immediate.” ❖

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PSYCHIATRIC RESEARCH INSTITUTE NORTHWEST

Mental Health Care in Northwest Arkansas 

Jon Rubenow, D.O., oversees the psychiatric residents at UAMS’ northwest Arkansas campus.

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Photo by Russell Cothren

By Jon Parham

SHOULD ANY of the 28 psychiatric inpatient beds at Northwest Medical Center in Springdale come open, they don’t stay that way for long. Yet it wasn’t in the too distant past that there were no inpatient psychiatric services in the fastgrowing northwest region of the state. The late 1990s and early 2000s saw a wave of inpatient psychiatry program closures at northwest Arkansas hospitals. But the need never went away, and as the region’s population increased, the lack of inpatient services grew even more serious, said Dan McKay, chief executive officer for Northwest Health System. So in 2009, the state, health care organizations and mental health providers joined forces with UAMS to develop the 28-bed adult mental health unit in a wing of Northwest Medical Center. Startup funding included more than $1 million allocated by Gov. Mike Beebe and more than $1 million appropriated by the state Legislature. Development of the unit was led by the grassroots Northwest Arkansas Acute Care Mental Health Task Force. The group included UAMS, Northwest Health System, Ozark Guidance, Care Foundation Inc., Washington Regional Medical Center and Mercy Health System of Northwest Arkansas. “It was too big a project for just one hospital system to take on — too expensive and too many resources required,” McKay said. “I think this has proven to be a successful private-public collaboration — coming together to take care of patients and fulfill a real community need for mental health care services. The inpatient unit is staffed by UAMS psychiatrists and psychiatry resident physicians who are a part of UAMS’ Psychiatric Research Institute Northwest. Jon C. Rubenow, D.O., division director for » www.uamshealth

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“I think this has proven to be a successful private-public collaboration.”

“I think we have many opportunities to expand our impact.”

the Psychiatric Research Institute Northwest, said because of the unique nature of the arrangement, “we are called on sometimes to treat patients who are having difficulty finding other options for care whether due to the complexity of the case or extenuating medical, social or legal issues. “Being based in a hospital offers us the ability to accept patients that might have been turned down at other types of facilities in addition to the resources — the staffing and infrastructure — to provide the comprehensive care patients need.” Another community need — mental health services for children in northwest Arkansas — is being met through the Centers for Children in Lowell, a collaboration of UAMS and Arkansas Children’s Hospital. UAMS board-certified child and adolescent psychiatrists there offer evaluation and treatment to children with

developmental disabilities. Access to pediatric subspecialty care, including a child psychiatrist, was a driving force in opening the Lowell facility in 2007. Child mental health services also are provided by UAMS through KIDS FIRST, a comprehensive, early-intervention program for infants and young children with medical conditions and developmental delays. KIDS FIRST provides medical and neuropsychological assessments for children with developmental issues. Rubenow said growth potential remains in all of the mental health programs in the region. “I think we have many opportunities to expand our impact and implement our mission, which includes helping patients and families as well as providing important clinical experience to students and resident physicians.” ❖

UAMS Northwest allows psychiatry residents and medical students to get clinical experience.

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UAMS Expands Psychiatry Training in Northwest Arkansas 

By Jon Parham

OPENING THE UAMS NORTHWEST regional campus in 2009 also opened doors of opportunity for medical students and resident physicians in the field of psychiatry. The campus expanded access to medical and mental health care with newly graduated physicians completing their residencies in the area. By starting their careers in Arkansas — a state with one of the lowest number of physicians per capita in the nation — there was a greater chance of staying in the state to continue their career. The psychiatry residents and medical students were able to gain valuable clinical experience at clinics, pharmacies and hospitals in northwest Arkansas. “Our program allows us to educate more psychiatrists, which addresses a need. Arkansas is chronically underserved and we cannot yet graduate enough to replace those who retire, die or move,” said Jon C. Rubenow, D.O.., division director for the Psychiatric Research Institute Northwest. “We have a smaller program here so our students and residents get an experience more like a psychiatrist in community practice with more interaction with other physicians and other mental professionals at all levels of the treatment process.” The UAMS College of Medicine has been recognized as one of the top medical schools in the nation for recruiting students to psychiatry. Medical students get the chance early to interact with practicing psychiatrists at UAMS. That exposure offers an important glimpse into the profession, said John Spollen, M.D., vice chair for education in the college’s Department of Psychiatry. “Some students will have preconceived incorrect notions about the type of work psychiatrists do or the kind of career you can have through negative stereotypes or the stigma sometimes associated with mental health issues,” Spollen said. UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

“I think the feedback we get from students and the number of medical students that choose psychiatry show that the experience they get at UAMS is quite positive.” The first psychiatric resident arrived at UAMS Northwest in 2011, the same year rotations of thirdand fourth-year medical students began there. Two physicians are now completing their psychiatry residency in northwest Arkansas. Rubenow said that number will grow to three or four residents in July 2014. The residents provide care for patients in the Psychiatric Research Institute Northwest Outpatient Clinic. Additionally, they work on a 28-bed inpatient unit that opened in May 2009 in Springdale’s Northwest Medical Center thanks to a community partnership that included the UAMS and the medical center as well as the local community mental health center Ozark Guidance Center. The three-week medical student rotation covers the UAMS Northwest medical programs in family medicine, obstetrics/gynecology and psychiatry. With block schedules, the students spend longer uninterrupted periods with each of the disciplines, giving them a more rounded, in-depth experience, Rubenow said. Rubenow called it a more community-based experience for students, seeing treatment given to patients in the psychiatric unit of Northwest Medical Center and in local mental health organizations such as Ozark Guidance Center. “The students witness active treatment of patients — some with very acute mental illness — so they see patients receive treatment and see them get better,” he said. “They are able to sit and talk to a variety of people, giving them a rich opportunity for learning, given the diversity of illnesses they see.” ❖

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STATE HOSPITAL

Forensic Patients Receiving Timely Care 

By Ben Boulden

“We're able to get people in more quickly and treat them more efficiently.”

WHEN AN ARKANSAS COURT orders that a defendant undergo a forensic psychiatric evaluation or treatment before standing trial for a crime, it turns to the Arkansas State Hospital. With almost all of its 12 psychiatrists and 13 psychologists employed by UAMS (many specializing in forensics), the State Hospital is a nine-unit, 226-bed psychiatric facility located just a few hundred yards west of the main UAMS campus. The hospital administers all Arkansas court orders for forensic evaluation and treatment and completes about 20 percent of the evaluations performed in the state. Once a forensic evaluation is performed, patients found incompetent to stand trial receive treatment to restore them to a mental state in which they can understand the legal process and aid in their own defense. Until 2012, all forensic treatment was performed on an inpatient basis at the State Hospital. An upward swing in court orders created longer waits for patients to get into the hospital for forensic treatment, until the medical staff developed a better way of honoring treatment orders. Partnering with community mental health centers, the hospital shifted from a system dependant on inpatient treatment to a mix of outpatient and inpatient treatment. The community mental health centers contracted with the hospital to provide the outpatient services, thus preventing unnecessary admissions. Through this partnership, the hospital and its UAMS staff have all but eliminated the backlog, and most of those few patients who are waiting are receiving outpatient treatment. “We’re able to get people in more quickly and treat them more efficiently,” said Steve Domon, M.D., the State Hospital’s medical director. www.uamshealth

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“People are seeing now that this is a sustained change for the better.” Domon said the new outpatient program has accomplished several things. People who need treatment are receiving it more quickly and effectively, and it is less likely that people will be incarcerated for weeks or months before receiving proper psychiatric care. “We’re also avoiding unnecessary hospitalizations,” he said. “We were admitting people simply because we had a court order, regardless of whether they needed inpatient treatment. We’re now using our beds more efficiently because many people can be treated effectively, sometimes more so, as an outpatient.” That means the State Hospital can do an even better job of honoring forensic orders and fulfilling its other major functions. In addition to administering and performing forensic evaluations and providing forensic treatment, it is responsible for monitoring patients who have been acquitted and conditionally released for a period of up to five years. The hospital also maintains units for the non-forensic general psychiatric care of adults as well as for the separate treatment of adolescents ages 13-17. In keeping with the medical education mission of UAMS, the State Hospital supervises junior and senior medical student rotations, postgraduate first-year psychiatry residents and child and adolescent psychiatry residents. It is also the primary site for the UAMS forensic psychiatry fellowship and a forensic psychiatry postdoctoral program. Domon said that the State Hospital is committed to improving the lives of Arkansans through education, and the UAMS faculty, fellows and residents are essential in fulfilling the core missions of the hospital. ❖ UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

The Arkansas State Hospital in Little Rock is staffed by UAMS psychiatrists and psychologists.

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PTSD VA RESEARCH

UAMS, VA Mental Health Research Takes National Role ď&#x192;¨

By David Robinson UAMS and the VA Hospital sit side by side, offering opportunities for researchers and clinicians to collaborate.

MORE THAN HALF-A-MILLION VETERANS enrolled in the U.S. Department of Veterans Affairs health care system are diagnosed with post-traumatic stress disorder (PTSD), and with suicide claiming the lives of an estimated 22 veterans every day, the pressure is on to find solutions. Mental health researchers at UAMS and the Central Arkansas Veterans Healthcare System (CAVHS) have joined forces to take a prominent role in this national effort. The research is led by some of the best minds in psychiatry and psychology as well as experts in geography, anthropology, nursing, pharmacy, religion and community engagement. Their laboratory extends across the country, including communities across Arkansas, which has more www.uamshealth

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than 250,000 veterans, placing it among states with the most veterans per capita at 10.4 percent. On the UAMS side, the effort is led by John Fortney, Ph.D., director of the Division of Health Services Research in the Department of Psychiatry in the College of Medicine. The division has more than 20 faculty members, and about 90 percent of them have joint appointments with CAVHS. Their work is augmented by other College of Medicine departments, the colleges of Nursing and Pharmacy, and the UAMS Translational Research Institute. The majority of the research is in developing, testing and implementing interventions for mental health and substance use disorders. Their discoveries and innovations have been adopted nationally by the VA. UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

The CAVHS Eugene J. Towbin Healthcare Center in North Little Rock is home to three mental health research centers, more than any VA site in the country. “We’re having a national impact, but in many ways it’s kind of a secret in Arkansas,” said Jo Ann Kirchner, M.D., a UAMS professor of psychiatry and director of one of those centers, the Mental Health Quality Enhancement Research Initiative (QUERI). Established in 1998, Mental Health QUERI is responsible for research on finding and implementing best clinical practices to improve treatment and outcomes for veterans with mental illness. Other mental health centers run by CAVHS in partnership with UAMS are: Mental Illness Research, Education and Clinical Centers (MIRECC), established by Congress in 1996. The South Central MIRECC covers the Florida panhandle to the panhandle of Oklahoma and includes 10 medical centers and 80 satellite clinics. The center focuses on improving access to mental health care for veterans in rural areas. Fortney is the South Central MIRECC’s associate director for research.

Center for Mental Healthcare and Outcomes Research (CeMHOR), directed by Richared Owen, M.D, a UAMS professor of psychiatry. Established in 1990, it conducts translational research to move findings into development of new treatments and find ways to ensure the best treatments are reaching veterans who need them.

Kirchner said having all three programs in central Arkansas is a tribute to the vision of College of Medicine Dean G. Richard Smith, M.D., former chair of the Department of Psychiatry and founding director of the UAMS Psychiatric Research Institute. “Dr. Smith was the founding director of CeMHOR and strongly encouraged and supported the application for the VA South Central MIRECC and Mental Health QUERI,” she said. UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Models of Success Fortney and Kirchner are behind one of the biggest success stories for mental health research at CAVHS. They developed ways to implement models of delivering mental health care in primary care clinics, and their work is being used by VA policy makers across the nation. With mental health providers co-located in the same clinic as veterans’ primary care physicians, patients may be referred on the spot without need of an appointment and without requiring a lengthy mental health evaluation. This is a change from patients being referred to mental health providers in a different building in a potentially stigmatized setting. “In many cases the patient has a specific problem that we can help them address immediately without having to go through a full psychosocial evaluation,” Fortney said. “It is very patient-centered and problem-focused.” Fortney and Kirchner consulted with front-line VA providers and staff in implementing the models, which they say has been key to its success. Care managers have been added to follow up with patients, such as making sure they understand their treatment plan, promoting medication and counseling adherence, and assessing treatment response. The biggest challenge has been in smaller medical centers and community-based outpatient clinics. Fortney adapted the integrated care model using telemedicine for smaller clinics that allows patients to speak with a mental health professional by telephone or interactive video. Kirchner has led the development of a strategy in which specially trained facilitators work with the clinics to develop and conduct implementation plans for integrated care models. The strategy was so effective that Kirchner was still analyzing the research data when VA leadership in Washington, D.C., requested that she start training VA staff as facilitators. “Ultimately, that’s the measure of success,” she said. Fortney agreed. “If researchers prove a treatment or program works, the VA will put it into practice.” ❖ www.uamshealth

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"If researchers prove a treatment or program works, the VA will put it into practice."

The Pew Versus the Couch The first and second meetings between local clergy and mental health providers in Russellville did not go well. Motivated by the suicide of a local veteran, they had gathered for lunch, invited by Chaplain Steve Sullivan from the Central Arkansas Veterans Healthcare System (CAVHS) and UAMS mental health researchers. By the second meeting, a mental health social worker said she didn’t plan on referring patients to the pastors she didn’t know or trust. At the same time, a pastor complained that he went to visit a parishioner in the hospital’s intensive care unit and wasn’t allowed in the room. The meetings were an outgrowth of the “VA/Clergy Partnership for Rural Veterans” project, a U.S. Department of Veterans Affairssupported effort to increase communication and understanding between local clergy and mental health providers. “Mental health providers tend to shy away from spirituality matters even though that integrates with mental health,” said Jeffrey Pyne, M.D., a professor of psychiatry and researcher for UAMS and CAVHS, “And the clergy tend to be suspicious of psychotropic medications as being the solution to what ails you.” Despite the rocky start, the project that started four years ago in El Dorado, Pine Bluff, Searcy and Russellville has been deemed by the VA’s Office of Rural Health as its most successful project,

VA Chaplain Steve Sullivan hopes to improve relationships between clergy and mental health professionals.

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said John Fortney, Ph.D., who leads the Division of Health Services Research in the Department of Psychiatry in the UAMS College of Medicine and also has a research leadership position at CAVHS. It is now being replicated in five other states. “Eventually, Arkansas will be the hub resource for VA clergy partnerships that will then begin to spread to other parts of the country,” said Sullivan, also a member of the UAMS Translational Research Institute’s Community Advisory Board. When the project wasn’t getting much traction with Russellville clergy, Sullivan gathered five local clergy and five mental health providers. The meetings began to bear fruit after a veteran told the mental health social worker that his posttraumatic stress disorder (PTSD) was a spiritual matter and he wanted to speak to a pastor. “She was able to look around the room and identify two or three pastors who she felt could help,” Sullivan said. About the same time, a pastor skeptical of the mental health community confided that a family member was battling depression, and he developed a trusting relationship with the same mental health social worker. The project was strengthened when Pyne spoke to the group, Sullivan said. Pyne noted that many veterans aren’t experiencing fear-based PTSD, but rather guilt and shame. The concept known as moral injury is a result of experiences or things veterans may have done that are not consistent with their moral upbringing and the way they understand the world. “Dr. Pyne said, ‘Look, we’re frustrated; we’re seeing a lot of guilt and shame and our PTSD interventions are not touching this. You guys are the experts on these kinds of things. Can you help us?’” “That totally changed the dynamic,” Sullivan said. “Pastors said they finally felt respected and they very much appreciated it.” Local clergy are now becoming vital partners in veterans’ mental health treatment, he said. The VA/Clergy Partnership project is sponsored and supported by the VA South Central Mental Illness, Research, Education, and Clinical Center (MIRECC). — David Robinson

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SEXUAL HEALTH AFTER VIOLENCE 

Encouraging Healthier Relationships

By Lauren Farabough

WOMEN WHO HAVE EXPERIENCED emotional abuse, physical violence or sexual violence are more likely to participate in sexual and drug use behaviors that increase their risk of acquiring a sexually transmitted infection, research shows. While there are effective therapies to help survivors cope with abusive experiences, little has been done to address their sexual risk behavior and help them have healthier sexual relationships in the future. Brooke EE Montgomery, Ph.D., M.P.H., assistant professor in the UAMS College of Public Health, is recruiting women for a pilot study aiming to do just that. “I truly have a heart for these women and helping them get the help they deserve,” Montgomery said. She decided to pursue the study after working on a project to help reduce sexual risk and hearing women talk about their experiences with physical and sexual violence. She heard their frustrations UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

and struggles to have healthy sexual relationships after surviving traumatic and violent life experiences. Funded by the UAMS Translational Research Institute, this study will include 30 to 50 women ages 18 to 64 who survived sexual, physical, and/ or emotional abuse. The women will complete eight, two-hour weekly sessions in which they will learn how to have healthier sexual relationships and address their thoughts and opinions toward men, sex, and relationships. Sessions will include exercises, demonstrations, and various activities with the goal of empowering these women to reduce unsafe sexual practices. “Mental health is a huge part of these women’s daily struggles, but this is not a therapeutic intervention,” Montgomery said. “There are several great resources for therapy and counseling. This program is designed to address the unique sexual health needs and considerations of women who have survived violence.” ❖ www.uamshealth

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DEPRESSION AND HEART DISEASE

College of Nursing Research Studies Genetic Link 

By Nate Hinkel

“It may be that these individuals require a combination of behavioral therapy and medication.”

IF SIGNS OF DEPRESSION in patients hospitalized for a heart attack are not recognized and treated, those patients are twice as likely to suffer a reoccurring coronary event. And with depression rates in those patients as much as three times greater than the general population, much can be done to improve those patients’ quality of life and ultimately cut down on future health care bills. Lorraine Frazier, Ph.D., R.N., dean of the UAMS College of Nursing, is conducting a fiveyear, $2.3 million National Institutes of Healthfunded study with a team of former colleagues at the University of Texas Health Science Center at Houston School of Nursing, where she previously worked and taught. The study focuses on depression and heart disease, and the role genetics plays in the link. In heart disease patients, it’s known that some have physiological changes in their inflammatory proteins when they are depressed. This change in these protein levels, although present throughout their lives in response to depression, becomes problematic as they develop heart disease. “When you’re older and you have vulnerable plaque in your coronary system, increased levels of inflammatory protein that can be initiated by depression can actually cause these plaques to rupture and result in a heart attack,” Frazier said. “So we’re looking to see if there’s a genetic propensity to those inflammatory protein levels in that group.” Frazier is looking at data from 1,200 patients who gave blood samples immediately upon entering the hospital because of a heart attack. When the patients are stable, depression and demographic data are also collected. “We are examining the interaction of the inflammatory protein levels, genetic variations in www.uamshealth

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those proteins, and depression data to determine which patients have a genetic predisposition to increased inflammatory protein levels when depressed,” Frazier said. “Different interventional approaches for depression may be necessary for this group. It may be that these individuals require a combination of behavioral therapy and medication to effectively treat depressive episodes.” Even more important, Frazier said, is that those patients be mindful of the potential for depression that may impact their cardiac health. “It is important that we identify and treat depression in this group because, if not treated, they are more susceptible to subsequent cardiac events,” she said. The research team is working with individuals who have been diagnosed with heart disease to test if behavioral interventions for depression impact inflammatory protein levels. “Our challenge is putting people in the best environment to support their health,” Frazier said. “There is great value in finding these people, educating them, and then challenging them to make changes in their environment that enable them to support a healthy lifestyle.” Sleep disturbance, which Frazier found in all cases of younger depressed female patients, is not a traditional cardiovascular risk factor, but the study suggests that symptoms of sleep disturbance are associated with cardiovascular disease. Frazier and her team are evaluating the impact of sleep symptom screening and sleep disturbance management. “Screening for symptoms of sleep disturbances may need to be particularly aggressive in women with cardiovascular disease with or without additional symptoms of depression,” Frazier said. “Young women with sleep disturbances may also represent a particularly vulnerable group.” ❖ UNIVERSITY OF ARK ANSAS FOR MEDICAL SCIENCES

Photo caption here.

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MENTAL HEALTH AND MINORITIES

Reaching African-Americans in the Delta 

By David Robinson

MENTAL ILLNESS is an equal opportunity disease, affecting whites and AfricanAmericans about the same. What is different, especially for AfricanAmericans in the Delta, are the barriers to mental health services, including perceptions that make them less willing to seek help. Two years ago a first-of-itskind study of the issue grew out of discussion with community 54

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advocates who have a history of partnership with UAMS and its Translational Research Institute. “Mental disorders are prevalent and disabling, and we know that African-Americans are less likely to get help,” said Greer Sullivan, M.D., M.S.P.H., a UAMS professor of psychiatry and the study’s principal investigator. Mental disorders affect 1 out of 10 men and 4 out

of 10 women, and depression is the second most disabling condition behind heart disease. “We also know that these disorders are influenced by stress,” said Sullivan, a veteran community-based researcher who formerly directed the Translational Research Institute’s Community Engagement program and was the institute’s co-principal investigator. “So when you live in

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poverty and you live with racism and in sub-optimal environmental conditions, you are under a lot more stress than someone who doesn’t.” Naomi Cottoms and Mary Olson, leaders of the Tri-County Rural Health Network, first discussed the mental health problem with Kate Stewart, M.D., M.P.H., a researcher at the UAMS Fay W. Boozman College of Public Health who has collaborated with the group on several research projects. Stewart then brought in Sullivan. The group developed a plan that resulted in UAMS earning

its first research grant from the national Patient Centered Outcomes Research Institute (PCORI), which requires researchers to make true partners of the communities they are studying. Traditionally, researchers would use focus groups with key stakeholder groups defined by investigators to find out how the community thinks about a given issue. The Tri-County group, however, uses public forums, a structured but more inclusive approach of engaging citizens to participate in decision-making. “We realized that Ms.

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Cottoms and Dr. Olson were doing something very innovative with community forums,” Sullivan said. “They’ve been doing them for a long time and they’ve done them primarily to get community input on a number of topics – not only topics related to health.” Based in Jefferson County, Sullivan’s PCORI study has used both focus groups and forums and is comparing the outcomes. She and other researchers on the study, including Geoff Curran, Ph.D., Ann Cheney, Ph.D., Tiffany Haynes, Ph.D., and Keneshia Bryant, Ph.D., have talked to a cross-section of people, including mental health providers, people with mental illness, clergy and college students. “We have literally talked to hundreds of people – real people in the real world,” Sullivan said. “That’s how we’ve come to understand these major issues from the point of view of the community.” The early take-away is that mental illness is poorly understood in the Delta. “There is both what we would call poor mental health literacy and a huge amount of stigma,” Sullivan said. Ultimately Sullivan hopes the pilot study data will lead to successful interventions. “We are planning our next study to test effective ways to address mental health literacy and stigma.” ❖ www.uamshealth

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“There is both what we would call poor mental health literacy and a huge amount of stigma.”

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University of Arkansas for Medical Sciences • Arkansas’ ONLY comprehensive academic health center • COLLEGES of Medicine, Nursing, Pharmacy, Health Professions and Public Health; and a Graduate School • A STATE-OF-THE-ART hospital • A STATEWIDE NETWORK of regional centers • Adavanced telehealth and telemedicine programs • Research funding of nearly $130 million across UAMS and UAMS researchers working in affiliated institutions. • SEVEN INSTITUTES: Winthrop P. Rockefeller Cancer Institute, Jackson T. Stephens Spine & Neurosciences Institute, Myeloma Institute for Research and Therapy, Harvey & Bernice Jones Eye Institute, Psychiatric Research Institute, Donald W. Reynolds Institute on Aging and Translational Research Institute. • Private support is ESSENTIAL TO OUR MISSION to engage in activities that result in better health. Please consider making a tax-deductible gift today by calling us at (501) 686-8200 or giving online at uamshealth.com/giving. All gifts are important and greatly appreciated. •

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