yale textbook of public psychiatry.1e.2016.unitedvrg.htd

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YA L E T E X T B O O K O F P U B L I C
P S Y C H I A T R Y
PUB LIC PSYCHI ATRY
E D I E D B Y
Selby C. Jacobs, MD P R O F E S S O R E M E R I U S O F P S Y C H I A R Y
A N D P U B L I C H E A L H
Jeanne L. Steiner, DO A S S O C I A E P R O F E S S O R O F P S Y C H I A R Y
E D I O R I A L B O A R D
Samuel A. Ball, PhD P R O F E S S O R O F P S Y C H I A R Y
Larry Davidson, PhD P R O F E S S O R O F P S Y C H I A R Y
Joanne DeSanto Iennaco, PhD, APRN A S S O C I A E P R O F E S S O R , S C H O O L O F N U R S I N G
Esperanza Díaz, MD A S S O C I A E P R O F E S S O R O F P S Y C H I A R Y
Thomas J. McMahon, PhD A S S O C I A E P R O F E S S O R O F P S Y C H I A R Y
A N D C H I L D S U D Y C E N E R
A S S O C I A E C L I N I C A L P R O F E S S O R
S C H O O L O F N U R S I N G
Robert M. Rohrbaugh, MD P R O F E S S O R O F P S Y C H I A R Y
Michael J. Sernyak, MD P R O F E S S O R O F P S Y C H I A R Y
Thomas H. Styron, PhD A S S O C I A E P R O F E S S O R O F P S Y C H I A R Y
Howard Zonana, MD P R O F E S S O R O F P S Y C H I A R Y
Y A L E S C H O O L O F M E D I C I N E
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First Edition published in 2016
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Library o Congress Cataloging-in-Publication Data Yale textbook o public psychiatry/edited by Selby C. Jacobs and Jeanne L. Steiner.
p. ; cm. extbook o public psychiatry
Includes bibliographical reerences and index. ISBN 978–0–19–021467–8 (alk. paper)
I. Jacobs, Selby, 1939–, editor. II. Steiner, Jeanne L., editor. III. itle: extbook o public psychiatry. [DNLM: 1. Community Mental Health Services—United States. 2. Community Psychiatry—United States. WM 30.6]
RC443 362.1968900973—dc23
Printed by Sheridan, USA
Tis material is not intended to be, and should not be considered, a substitute or medical or other proessional advice. reatment or the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate inormation with respect to the subject
matter covered and to be current as o the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules or medications are being revised continually, with new side effects recognized and accounted or reg ularly. Readers must thereore always check the product
inormation and clinical procedures with the most up-to-date published product inormation and data sheets provided by the manuacturers and the most recent codes o conduct and saety reg ulation. Te publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness o this material. Without limiting the oregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy
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8/18/2019 Yale Textbook of Public Psychiatry.1E.2016.UnitedVRG.htd
To people recovering fom serious mental illnesses and substance use disorders and to those who serve them
through clinical services, education, and research.
Foreword ix
Preface xi
Acknowledgments xiii
Contributors xv
1. Introduction and Significance 1 Selby C. Jacobs, Samuel A. Ball, Larry Davidson,
Esperanza Díaz, Joanne DeSanto Iennaco, Tomas J. McMahon, Robert M. Rohrbaugh,
Jeanne L. Steiner, Tomas H. Styron, Michael J. Sernyak, and Howard Zonana
PAR I
T HE SER VI CE SYST EM
O F P UBL I C P SYCHI A T R Y
2. Te Service System o Public Psychiatry 15 Selby C. Jacobs, Andres Barkil-Oteo, Paul DiLeo,
Patricia Rehmer, and Larry Davidson
3. Recovery and Recovery-Oriented Practice 33 Larry Davidson, Janis ondora, Maria J. O’Connell, Chyrell Bellamy, Jean- Francois Pelletier, Paul DiLeo,
and Patricia Rehmer
4. Community Supports and Inclusion 49 Tomas H. Styron, Janis L. ondora,
Rebecca A. Miller, Marcia G. Hunt, Laurie L. Harkness, Joy S. Kaufman, Morris D. Bell, and Allison N. Ponce
PAR II
SYST EM I N T EG R AT I O N CHA LLE N G ES
I N P UBL I C P SYCHI A T R Y
5. Integrated Health Care 63 Aniyizhai Annamalai, Cenk ek, Michael J. Sernyak, Robert Cole, and Jeanne L. Steiner
6. Substance Use Disorders and Systems o Care 81 Donna LaPaglia, Brian Kiluk, Lisa Fucito, Jolomi Ikomi, Matthew Steinfeld, and Srinivas Muvvala
7. Public Health Concepts in Public Psychiatry 97 Joanne DeSanto Iennaco, Jacob Kraemer ebes, and Selby C. Jacobs
8. Te Interplay Between Forensic Psychiatry and Public Psychiatry 115
Reena Kapoor, Susan Parke, Charles C. Dike, Paul Amble, Nancy Anderson, and Howard Zonana
PAR III SER VI CES A N D CLI N I CA L
CO MP ET EN CI ES O F P UBLI C P SYCHI A T RY
9. Children, Adolescents, and Young Adults in the Publicly Funded System o Care 133 Tomas J. McMahon, Nakia M. Hamlett, Christy L. Olezeski, imothy C. Van Deusen,
Natasha Harris, and Doreen J. Flanigan
10. Early Intervention and Prevention or Psychotic Disorders 155
Jessica M. Pollard, Cenk ek, Scott W. Woods,
Tomas H. McGlashan, and Vinod H. Srihari 11. Hospital Services 171
Charles C. Dike, Marc Hillbrand, Richard Ownbey, Daniel Papapietro, John L. Young, Srinivas Muvvala, and Selby C. Jacobs
12. Outpatient Behavioral Care Services 185 Deborah Fisk, Joanne DeSanto Iennaco, Donna LaPaglia, and Aniyizhai Annamalai
13. Clinical Competence in Outreach and or Special Populations 197
Anne Klee, Lynette Adams, Neil Beesley, Deborah Fisk, Marcia G. Hunt, Monica Kalacznik, Howard Steinberg, and Laurie Harkness
14. Cultural Competence and Public Psychiatry 211 Esperanza Díaz, Michelle Silva, Elena F. Garcia-Aracena, Luis Añez, Manuel Paris, Andres Barkil-Oteo, Aniyizhai Annamalai, Miriam Delphin- Rittmon, and Selby Jacobs
15. Global Mental Health 223 Carla Marienfeld, Andres Barkil-Oteo,
Aniyizhai Annamalai, and Hussam Jefee- Bahloul
v i i i • C O N T E N T S
P AR I V
SYST EM DEVELO P MEN T
I N P UBL I C P SYCHI A T RY
16. Education and Workorce Development in Public Psychiatry 235
Jeanne L. Steiner, Chyrell Bellamy, Michael A. Hoge,
Joanne DeSanto Iennaco, Anne Klee, Allison N. Ponce, Robert M. Rohrbaugh, David A. Ross, Tomas H. Styron, and Selby C. Jacobs
17. Evidence-Based Public Psychiatry 249 Jack sai, Joanne DeSanto Iennaco, Julienne Giard, and Rani A. Hoff
18. Administrative Best Practices in Public Psychiatry 261 Andres Barkil-Oteo, Margaret Bailey, Robert Cole, Miriam Delphin- Rittmon, Susan Devine, Selby C. Jacobs, Jeanne L Steiner, Louis revisan,
and Michael J. Sernyak
19. Conclusion and Future Challenges 273 Selby C. Jacobs, Samuel A. Ball, Larry Davidson,
Esperanza Díaz, Joanne DeSanto Iennaco,Tomas J. McMahon, Robert M. Rohrbaugh, Jeanne L. Steiner, Tomas H. Styron, Michael J. Sernyak, and Howard Zonana
Index 287
ix
FOREWORD
he emergence o this important textbook on public psychiatry signals a new era o transormative work in this area rom a department with a long
and distinguished history in the field. Te Yale Department o Psychiatry was established by the Yale Medical School in 1930, under the leadership o Eugen Kahn, a protégé o the pioneer Emil Kraeplin. However, the Department emerged in its current orm in 1948, as a result o a undamental
restructuring o its mission and organization under theleadership o Francis (“Fritz”) Redlich, who was chair o the Department or 20 years. Dr. Redlich was a pioneer in public psychiatry whose research identified significant disparities in mental health treatments available to patients rom upper socioeconomic groups compared with those available to poor patients in New Haven, as documented in his seminal book Social Class and Mental Illness. Trough his personal example and through his leadership, Dr. Redlich demonstrated his commitment to the development o public psychiatry as an academic discipline with prominence in the Department equal to that o biological and psy-
chological research. In 1957, Dr. Redlich began pioneering discussions with Abraham Ribicoff, then Governor o Connecticut, about the creation o a public psychiatry institute to address mental health disparities. Afer President Kennedy signed the Community Mental Health Center Act in 1963, Dr. Redlich implemented these plans with ederal and state assistance. Te Connecticut Mental Health Center (CMHC), opened in 1966, remains an exemplar o a public–academic partnership between the State o Connecticut Department o Mental Health and Addiction Services and Yale University. As we near the 50th anniver-
sary o CMHC’s ounding, Dr. Redlich’s vision o a public psychiatry institute ostering lively interdisciplinary aculty exchanges leading to improved outcomes or patients in the public sector has been ully realized. Te programs at CMHC, including a clinical neuroscience unit to develop new biological treatments, have helped vulnerable and dis- advantaged populations, with a special emphasis on those rom ethnic and cultural minorities. Te public psychiatry research portolio at CMHC helped establish the evidence
base or many public psychiatry clinical interventions and currently includes projects on ensuring patient’s perspectives are included in service development and delivery, prevention o mental health disorders through school-based interventions, early interventions or patients with emerg- ing psychotic symptoms, jail diversion or patients with mental illness in the justice system, and interventions or patients with addictions. A recent partnership between the
CMHC and a local Federally ualified Health Center provides an opportunity to explore integrated medical and psychiatric care and wellness or indigent people with serious mental illnesses and/or addictions.
Although the CMHC was ounded to promote a public psychiatry mission, Yale aculty at the VA Connecticut Healthcare System (VACHS), Yale-New Haven Hospital (YNHH), and other affiliated sites in the Yale Department o Psychiatry have also made substantial contributions to the field. Over the past three decades, VA Connecticut has been a leader in pioneering and evaluating psychosocial rehabilitation programs, many o which have been
disseminated widely within the national VA system. Te Errera Community Care Center at VA Connecticut is widely viewed as a national model or the integration o recovery-oriented psychosocial rehabilitation into the continuum o mental health care. reatment or many patients at the YNHH, a general, not-or- profit hospital, is reim- bursed by Medicaid and Medicare. With the expansion o Medicaid eligibility in Connecticut under the Affordable Care Act, the YNHH is increasingly serving patients previously treated in public psychiatry settings. Evidence o the importance o the public psychiatry mission across all
three institutions in the Yale Department o Psychiatry can be ound in the contributions o 74 o our aculty members to this textbook.
Our public psychiatry aculty members provide outstanding training to students o the health proessions. Medical students and psychiatric residents have opportunities to work on interdisciplinary teams caring or highly stigmatized, vulnerable patients, alongside nursing, psychology, and social work trainees. Community mental
x • F O RE W O RD
health workers, some o whom are also consumers o mental health care, provide an important recovery-oriented perspective to our trainees’ education. Our aculty members have developed toolboxes to educate others in culturally sensitive mental health care. Exposing trainees rom various disciplines to a public psychiatry perspective and to compel- ling state-o-the-art clinical care and research programs has
inspired generations o our trainees to become involved in public psychiatry careers. Opportunities to gain additional specialized expertise are available through highly regarded advanced ellowships in public psychiatry and in psychosocial rehabilitation. Te deep public–academic partnerships between the Yale Department o Psychiatry and the State o Connecticut at CMHC, and our Department and the ederal government at VACHS, have been and continue to be mutually beneficial to each partner. Te public part- ners have provided invaluable support, and, in return, the academic partner has advocated or the mission, educated
large numbers o proessionals who pursue careers withinthe public psychiatry system, and developed national model programs that provide the evidence base to meet
contemporary challenges in public psychiatry. Tese widely disseminated programs illustrate our commitment to meet the challenge o the Yale Department o Psychiatry’s mission statement to diminish the disability caused by mental illness. We commend this textbook to the next generation o proessionals and leaders o public psychiatry.
Robert M. Rohrbaugh, MD Proessor and Deputy Chair or Education
and Career Development Residency Program Director
Department o Psychiatry Director, Office o International Medical Student
Education Yale University School o Medicine
John H. Krystal, MD
Robert L. McNeil, Jr. Proessor o ranslational Research and Proessor o Neurobiology
Chair, Department o Psychiatry Yale University School o Medicine Chie o Psychiatry, Yale-New Haven Hospital
PREFACE
his textbook is authored and edited by aculty members o the Yale Department o Psychiatry who practice, teach, and conduct clinical and eval-
uative research in public psychiatry. It is a comprehensive, integrated, and interdisciplinary introduction to public psychiatry or advanced proessional students. As such, it is conceived in relation to the core, discipline-based educational programs o proessional students. It is guided by uni-
fied educational aims, a shared teaching philosophy, and anintegrated perspective (public psychiatry in relation to primary care, addiction medicine, public health, and orensic psychiatry) with regard to the service system and practices o public psychiatry. It emphasizes the competencies necessary or proessional careers in public psychiatry.
Interdisciplinary proessional education is a central tenet o the educational philosophy o this textbook. Tis education principle stems rom a conviction that interdisciplinary team practice is the best organizational unit or providing services within a system o care to people with serious mental i llnesses and substance use disorders.
Essentially, the authors and editors believe that those who learn together—not only about the elements o care and the system, but also about their respective strengths, limitations, and proessional aspirations— will practice better together. Te net result is a stronger service unit that serves as a cornerstone o the workorce o public psychiatry. Although coming rom an academic setting in a particular locality in the United States, the description o American public psychiatry in the textbook is generally applicable to other settings. All programs in public psychiatry serve a population o individuals with
serious mental illnesses and substance use disorders. In every locality, ederal policies and unding sources support and shape the service structures or this population. Proessionals in public psychiatry, through meetings and publications, shape universal practices. Shared evidence- based practices unite practice in public psychiatry across the country. Despite variation rom state to state and locality to locality, a basic oundation and knowledge base o public psychiatry prevails.
Although intended as a textbook or use in advanced, year-long internships or ellowships in public psychiatry, selected chapters can also serve as an introductory module or beginning proessional students. For example, the first our chapters include an introduction to public psychiatry by providing definitions or terms such as serious mental illnesses and substance use disorders, a discussion o the service system o public psychiatry, an introduction to recovery
concepts and practices, and a description o communitysupports and inclusion programs. Other chapters might be chosen or an introductory module given the educational aims o an introductory module.
Tis textbook is timely or a number o reasons. Health care reorm under the Affordable Care Act considerably expands access to behavioral services or previously unin- sured people. Medicaid is a vehicle or much o the expansion. Tose gaining coverage under Medicaid will gravitate to community health centers and behavioral health centers or care. Meeting this new demand or service requires an expanded and well-trained workorce. Already, depart-
ments o psychiatry are anecdotally reporting an increase in applicants interested in public psychiatry. Many advanced ellowships in public psychiatry already exist, but more will be needed to provide essential interdisciplinary education while working with the target population within a public service system.
In a concluding chapter, this textbook suggests that academic centers o public psychiatry can play an essential role in moving the field orward. Academic divisions o public psychiatry that bring together veterans’ services and state- unded services, or example, can make rich contributions
to their home departments. Some departments o psychiatry already have such divisions, and others are contemplat- ing it. In this regard, July 1 and September 28, 2016, mark, respectively, the 50th anniversary o the opening and the dedication o the Connecticut Mental Health Center in the Yale Department o Psychiatry, an illustration o an endur- ing, mutually beneficial partnership between the State o Connecticut and Yale University. In part, this textbook is a celebration o that anniversary.
x i i • PRE F A C E
As noted earlier, this textbook is intended primarily or advanced, proessional students o public psychiatry. Certainly, psychiatric educators will also take an interest, not only those directly teaching public psychiatry but also other aculty members involved in departmental education, in order to appreciate how public psychiatry may fit into a broader curriculum. Te textbook may also be o inter-
est to public administrators who wish or an overview o the field. Finally, the textbook may be useul to people, such as individuals in recovery rom serious mental illnesses and substance use disorders, and their amilies, who are seeking a greater understanding o treatment approaches and community supports available to them.
Although the editors and authors have done their utmost to provide a comprehensive introduction to current, public psychiatry, given the anticipated transitions in public psychiatry over the next several years, it is almost inevitable that the content o the textbook will become outdated. Te authors and editors anticipate this possibility. Accordingly, the textbook will be updated regularly
to reflect new developments. Te authors and editors are pursuing academic careers in public psychiatry and will be inormed o transitions that are occurring. In addition, they welcome eedback rom readers o the textbook about omissions or needed updates.
Te Editorial Board March 31, 2015
ACKNOWLEDGMENS
he Editors are grateul or support rom the Connecticut Department o Mental Health and Addiction Services and the Department o
Psychiatry o the Yale University School o Medicine. We thank Annette Forte and Nina Levine or their editorial assistance.
CONRIBUORS
All authors are aculty members within the Yale Department o Psychiatry, who hold academic appointments at the Yale School o Medicine, Yale School o Nursing, Yale Child Study Center and/or the Yale School o Public Health
Lynette Adams, PhD
Assistant Clinical Proessor Women Veterans Program Manager VA Connecticut Healthcare System
Paul Amble, MD
Assistant Clinical Proessor Chie Consulting Forensic Psychiatrist C Department o Mental Health Service
Nancy Anderson, APRN
Luis Añez-Nava, PsyD
Associate Proessor
Director, Hispanic Clinic Connecticut Mental Health Center Director, C Latino Behavioral Health System
Aniyizhai Annamalai, MD
Assistant Proessor Medical Director, Wellness Center Connecticut Mental Health Center
Margaret Bailey, LCSW
Samuel A. Ball, PhD
Proessor Assistant Chair or Education and Career Development President and Chie Executive Officer, CASA Columbia
Andres Barkil-Oteo, MD, MSC
Assistant Proessor Medical Director, Acute Services Connecticut Mental Health Center
Neil Beesley, LCSW
Morris D. Bell, PhD, ABPP
Proessor Senior Research Career Scientist Department o Veterans Affairs, Rehab R&D Program Director, NIMH Research Fellowship in Functional Disability Interventions
Chyrell D. Bellamy, PhD, MSW Assistant Proessor Director o Peer Services and Research Yale Program or Recovery and Community Health
Robert Cole, MHSA
Larry Davidson, PhD
Proessor Director, Yale Program or Recovery and Community Health
Miriam Delphin-Rittmon, PhD
Assistant Proessor Commissioner, C Department o Mental Health and Addiction Services
xv i • C O N T R I B U T O R S
Joanne DeSanto Iennaco, PhD, APRN
Associate Proessor Specialty Coordinator, Psychiatric-Mental Health Nurse Practitioner Program Yale School o Nursing
Susan Devine, APRN
Lecturer Director, New Haven Office o Court Evaluations Director, Risk Management Connecticut Mental Health Center
Esperanza Díaz, MD
Associate Proessor Medical Director, Hispanic Clinic Connecticut Mental Health Center Medical Director, C Latino Behavioral Health System Associate Director,
Psychiatry Residency Program
Assistant Proessor Associate Program Director, Fellowship in Forensic Psychiatry Deputy Medical Director, Department o Mental Health and Addiction Services
Paul J. DiLeo, FACHE
Lecturer Chie Operating Officer, Department o Mental Health and Addiction Services
Deborah Fisk, PhD, LCSW
Doreen Flanigan, LCSW
Lisa Fucito, PhD
Assistant Proessor Program Director, obacco reatment Smilow Cancer Hospital at Yale- New Haven
Elena F. Garcia- Aracena, MD
Clinical Instructor Attending Psychiatrist, Hispanic Clinic Connecticut Mental Health Center
Julienne Giard, LCSW
Lecturer Director, Evidence-Based Practices C Department o Mental Health and Addiction Services
Nakia M. Hamlett, PhD
Assistant Proessor Clinician, Young Adult Service Connecticut Mental Health Center
Laurie L. Harkness, MSW, PhD
Clinical Proessor Director, Errera Community Care Center VA Connecticut Healthcare System
Natasha Harris, APRN
Lecturer Clinician, West Haven Mental Health Clinic and Young Adult Service Connecticut Mental Health Center
Marc Hillbrand, PhD
Assistant Clinical Proessor Former Chie o Psychology, Connecticut Valley Hospital
Rani A. Hoff, PhD, MPH
Proessor Associate Director, Robert Wood Johnson Clinical Scholars Program
Director, Northeast Program Evaluation Center, Office o Mental Health Operations, Department o Veterans Affairs Director, Evaluation Division, National Center or PSD
Michael A. Hoge, PhD
Proessor Director, Yale Behavioral Health Director, Clinical raining in Psychology
Marcia G. Hunt, PhD
Jolomi Ikomi, MD
Assistant Proessor Former Medical Director, Substance Abuse reatment Unit Connecticut Mental Health Center
C O N T R I B U T O R S • x v i i
Selby C. Jacobs, MD
Hussam Jefee-Bahloul, MD
Reena Kapoor, MD
Joy S. Kaufman, PhD
Associate Proessor Deputy Director or Operations, Yale Consultation Center Director, Evaluation Research, Division o Prevention and Community Research
Brian Kiluk, PhD
Anne Klee, PhD
Assistant Proessor Director, Peer Services and Education and raining, Errera Community Care Center Director, Interproessional Residency in Psychosocial Rehabilitation and Recovery Services VA Connecticut Healthcare System
John H. Krystal, MD Robert L. McNeil, Jr. Proessor o ranslational Research and Proessor o Neurobiology Chair, Department o Psychiatry Chie o Psychiatry, Yale-New Haven Hospital
Donna LaPaglia, PsyD
Assistant Proessor Director, Substance Abuse reatment Unit Connecticut Mental Health Center
Carla Marienfeld, MD
Assistant Proessor Site raining Director, Yale Addiction Psychiatry Fellowship Director, Psychiatry Residency Global Mental Health Program
Tomas H. McGlashan, MD Proessor Emeritus & Senior Research Scientist Founder, PRIME Psychosis Prodrome Research Clinic
Tomas J. McMahon, PhD
Associate Proessor Director, West Haven Mental Health Clinic and Young Adult Service Director o Clinical Research Connecticut Mental Health Center
Rebecca A. Miller, PhD
Assistant Proessor Director, Peer Support Connecticut Mental Health Center
Srinivas Muvvala, MD, MPH
Assistant Proessor Medical Director, Substance Abuse reatment Unit Connecticut Mental Health Center
Maria J. O’Connell, PhD
Associate Proessor Research & Evaluation Area Leader Yale Program or Recovery and Community Health
Christy L. Olezeski, PhD
Assistant Proessor Clinician, Young Adult Service Connecticut Mental Health Center
Richard Ownbey, MD
Assistant Clinical Proessor Director o Medical Education, Connecticut Valley Hospital
Daniel Papapietro, PsyD
Assistant Clinical Proessor Chie o Psychotherapy Services, Connecticut Valley Hospital
xv i i i • C O N T R I B U T O R S
Manuel Paris, PsyD
Associate Proessor Deputy Director, Hispanic Services Connecticut Mental Health System
Susan Parke, MD
Assistant Proessor
Jean Francois Pelletier, PhD
Assistant Clinical Proessor Psychologist, Yale Program or Recovery and Community Health
Jessica M. Pollard, PhD
Assistant Proessor Director o Clinical Services, Program or Specialized reatment Early in Psychosis [SEP] Connecticut Mental Health Center
Allison N. Ponce, PhD
Associate Proessor Associate Director, Community Services Network o Greater New Haven Connecticut Mental Health Center
Patricia Rehmer, MSN
Former Commissioner, C Department o Mental Health and Addiction Services
Robert M. Rohrbaugh, MD
Proessor and Deputy Chair or Education and Career Development Residency Program Director, Department o Psychiatry Director, Office o International Medical Student Education, School o Medicine
David Ross, MD, PhD
Michael J. Sernyak, MD
Proessor Chie Executive Officer, Connecticut Mental Health Center Deputy Chair, Clinical Affairs and Program Development, Department o Psychiatry Director, Division o Public Psychiatry
Michelle Silva, PsyD
Assistant Proessor Associate Director, C Latino Behavioral Health System
Vinod H. Srihari, MD
Associate Proessor Director, Program or Specialized reatment Early in
Psychosis [SEP] Connecticut Mental Health Center Associate Director, Psychiatry Residency Program
Howard Steinberg, PhD
Jeanne L. Steiner, DO
Associate Proessor Medical Director, Connecticut Mental Health Center Director, Yale Fellowship in Public Psychiatry
Matthew Steinfeld, PhD
Tomas H. Styron, PhD
Greater New Haven Connecticut Mental Health Center
Jacob Kraemer ebes, PhD
Proessor Director, Division o Prevention and Community Research Director, Te Consultation Center Chie Psychologist, Connecticut Mental Health Center Director, NIDA 32 Postdoctoral Research raining Program in Substance Abuse Prevention
Cenk ek, MD Associate Proessor Director, Psychosis Program Connecticut Mental Health Center
Janis L. ondora, PsyD
Assistant Proessor Systems ransormation Area Leader Yale Program or Recovery and Community Health
C O N T R I B U T O R S • x i x
Louis revisan, MD
Associate Proessor Associate Chie, Mental Health Service Line VA Connecticut Healthcare System
Jack sai, PhD
Assistant Proessor
Co-Director, Yale Division o Mental Health Services and reatment Outcomes Research
imothy C. VanDeusen, MD
Assistant Proessor Medical Director, West Haven Mental Health Clinic and Young Adult Service Connecticut Mental Health Center
Scott W. Woods, MD
Proessor Chie, PRIME Psychosis Prodrome Research Clinic Attending Psychiatrist, Connecticut Mental Health Center
John L. Young, MD, MT
Clinical Proessor
Howard Zonana, MD
Proessor Director, Law and Psychiatry Division Director, Fellowship in Forensic Psychiatry
INTRODUCTION AND SIGNIFICANCE
Selby C. Jacobs, Samuel A. Ball, Larry Davidson, Esperanza Díaz, Joanne DeSanto Iennaco,
Tomas J. McMahon, Robert M. Rohrbaugh, Jeanne L. Steiner, Tomas H. Styron,
Michael J. Sernyak, and Howard Zonana
E D UC ATI O N AL H I G H L I G H TS
• Public psychiatry encompasses special clinical competencies or practice in a complex system
designed to serve the needs o people with serious mental illnesses (SMIs) and/or substance usedisorders (SUDs).
• Public psychiatry is particularly important at this moment in history, as public sector practice is considerably expanded under the Affordable Care Act o 2010.
• Public psychiatry is a large sector o the field o psychiatry, one that makes an essential impact on the lives o people with SMIs and SUDs.
• Te educational principles that guide this textbook derive rom a commitment to an integrated system o care inormed by public health.
• Important eatures o the service system include person-centered care, recovery orientation, interdisciplinary teams, community-based practice, cultural competence, integrated practice, population- based practice, evidence-based practice, and quality assurance, including peer and amily satisaction.
Te educational principles o this textbook include the development o advanced interdisciplinary education (assuming basic clinical skills are already in place), integration o all aspects o practice, attention to a ull range o services, and the cultivation o continuing sel-education in a structure o supervised clinical placements, seminars, and aculty supervision.
I N T R O D U C T I O N
Mental health proessionals who specialize in public psy-
chiatry must master a body o knowledge and domain o practice. What is public psychiatry? Who does public psychiatry serve? Does practice require special skills? Is there a special system o services or public psychiatry? Are there special educational needs or people interested in entering public psychiatry? What is the special content, i any, o education in public psychiatry? Is a textbook needed at this point in time? What are the educational principles o this
textbook? Tis introduction sets out to answer these ques- tions and thereby previews the education in public psychiatry embodied in this book.
W H AT I S P UB L I C P SYC H I AT RY ?
Building on definitions offered by others,1,2 this textbook uses the ollowing definition o public psychiatry 3: public psychiatry is that part o the practice o psychiatry that is (1) financed by the general unds o state departments
2 • I N T R O DU CT I O N
o mental health or (2) by reimbursement income rom entitlements such as Medicaid. For disabled, chronically ill individuals, Medicare also unds acute services, with eligibility determined by the Social Security Administration. In addition, the US Department o Housing and Urban Development supports residential services. Public psychiatry provides a saety net o services or low-income persons
with serious mental illnesses (SMIs) and co-occurring or independent substance use disorders (SUD). Te practice o public psychiatry incorporates evidence-based treatments, psychosocial rehabilitation, person-centered recovery plans o care, integration with primary care through medical homes, integration with substance use services, community supports such as housing and money management, and attention to social issues such as legal status, child protection, or homelessness. Public psychiatry is practiced in many settings. Tese include mental health and addiction agencies, community health centers, residential and nursing care acil-
ities, psychosocial rehabilitation agencies, hospital-based primary care centers, and organizations offering orensic or public health programs. Practice typically occurs through interdisciplinary teams (IDs). Also, given the multiplicity o settings and tasks, and also given the organizations such as community mental health centers or community health (primary care) centers where public psychiatry is practiced, system knowledge, management skills, and a community perspective are important or clinical success. Public psychiatry uses not only a clinical perspective while caring or the individual service user, but also a population perspective. It attends to public health data, epidemiologic studies, and health services research or the purpose o planning, evaluating, implementing, and managing services.
Tis definition o public psychiatry incorporates elements rom major historical and policy developments since 1963, when Congress enacted the Community Mental Health Centers Act during the Kennedy Administration.3 Te definition is proessional, medical, clinical, and administrative. It incorporates a broad clinical and public health perspective on psychiatric disorders and clinical services. Because public practice now takes place in both private and public locations, blurring the distinction between these
two settings, this definition avoids the trap o defining public psychiatry in terms o the place or system where it is practiced.
Psychiatric services o the Veteran’s Administration (VA) Healthcare System are not included in this definition, nor are they routinely incorporated into definitions o public psychiatry. Te VA is sufficiently distinct as a national health service or veterans that it deserves separate consideration. Te VA system deserves and, indeed, would require
an entire textbook itsel. Still, public psychiatry can learn much rom many parallel programs in the VA system, such as outreach programs, rehabilitation programs, and services research. Indeed, some veterans move back and orth between the systems and differ in their preerences or public versus veteran services. Tis textbook takes advantage o the overlap between the systems and cites VA programs and
examples in subsequent chapters. In the Yale Department o Psychiatry, aculty members at the Connecticut Mental Health Center and the West Haven Campus o the VA Connecticut Healthcare System collaborate in teaching and investigations and make up a departmental academic division o public psychiatry (see Chapter 19) devoted to education and research.
Te chapters ollowing this introduction ampliy a description o the service system o public psychiatry; subsequent chapters address clinical competence, and additional chapters cover additional skills and themes that are
important or successul practice in public psychiatry.
W H O I S S E RV E D BY P UBL I C P S YC H I ATRY?
Tere is no simple answer to the question o who is served by public psychiatry. Te short answer is that public psychiatry serves both children and adults who suffer rom SMIs and/or addictions and who sometimes make up special populations, such as people with traumatic brain injury or problematic sexual behavior, that all to state responsibility to provide care to, i not protect society rom.
Te term “serious mental illness” is ofen used to reer to the disorders o the core, target population served by public psychiatry. Te term “serious mental illness” was coined to denote people with severe, recurrent, chronic, or persistent disabling mental illnesses and addictions.4,5 It is used interchangeably in this text with “severe and persistent mental illness ,” a term that originated in studies done in the Yale Department o Psychiatry.6 SMIs typically include schizophrenia spectrum disorders with residual symptoms; recurrent bipolar illness; chronic,
relapsing depressive disorders; severe anxiety syndromes; and severe personality disorders, all with comorbidity and psychosocial disabilities. When substance abuse is added into the picture, which is ofen the case, SMI becomes even more challenging to treat. On the substance abuse side, severe addictions can be intractable and are ofen multiple, chronically relapsing, and disabling. Many o these chronic disorders are also associated with the risk o suicide and/or a risk o violence to others. As noted
I N T R O DU CT I O N • 3
earlier, public psychiatry also cares or special populations, many o whom have severe and persistent illness as defined and or whom the state takes responsibility to provide care and to protect society in circumstances o high risk. In epidemiologic studies, which estimate a 26% prevalence o all psychiatric illnesses in the American population, about 6% o the total population have the
most serious illnesses (see Chapter 7). Indeed, the population that public psychiatry serves is one o the most salient characteristics o public practice.
Te root causes or psychiatric illnesses remain unknown. Although evidence-based treatments relieve symptoms, and recovery occurs in the community, cures are rarely achievable. Estimates o shortened lie expectancy and years lost to disability rom SMIs, known as burden o disease, place them among the top ten o all kinds o diseases (see Chapter 7). As the Mental Health Services Act o 1980 asserted, persons with SMIs served in the public sector are
the most needy and vulnerable o all the people served byAmerican psychiatry and medicine. Te pathway o a person with SMI or a SUD into public
sector services varies by the nature o the illness, the course o illness over time, and access to care. Historically, examples have included young people with psychotic disorders who are no longer eligible or health insurance coverage under their parents and persons or whom the limited insurance benefits offered or treatment o psychiatric disorders have been exhausted. Also, many people become incapacitated and unemployed, thus making employer-based insurance inaccessible. How these various scenarios will change with current health reorm efforts remains to be seen. Many people living in poverty are eligible or Medicaid and, once an illness is chronic, Medicare. Tese payers can serve as a pathway into the system. Finally, many people with SMIs or SUDs are identified primarily, at least at first, by a major social problem, whether it is homelessness, o which about 40% are considered seriously ill, or people transitioning out o prisons, o which about 80% are estimated to have SUDs.
In contrast to the rest o psychiatric practice, is there something distinct or different about those people with mental health and SUDs who are served by public psy-
chiatry? Arguably, the answer is yes. Te illnesses typically encountered in public practice are chronic and associated with disability. It is this combination o acute, ofen recurrent illness; chronic residual symptoms; comorbidity with various other psychiatric disorders, mental health disorders and addictions, and physical health problems; disabilities; the need or psychosocial rehabilitation and community supports; and aspirations or recovery as well as ull citizenship that characterizes the typical person served in the
public system. Furthermore, social problems o poverty, legal embroilments, and homelessness are commonplace and intermingle inextricably with the clinical picture. Tis clinical complexity is a hallmark o the population served.
Te target population o people served by public psychiatry has varied over the years since inception o the modern era in 1963. Tis variation has been a unction o
ongoing budget crises and policy initiatives that invariably lead to discussions o exactly who is the target population. (See Chapter 2 or a brie discussion o the major periods o modern public psychiatry.) At first, during the 1970s, the definition o the target population emphasized those who resided in a particular community (the so-called catchment in the community mental health lexicon), especially those coming out o state hospitals.
Next, as the system seemed to be ailing people with chronic conditions who were discharged rom hospitals into the community, the definition o the target popula-
tion swung to people with severe and persistent mentalillness living in the community. During the same time in the 1980s, the target population slowly expanded as states began to use Medicaid to finance services. In these circumstances, the definition o the target population emphasized payer status and those eligible or Medicaid. Many o these people had SMIs or SUDs; however, many others who were single and poor were excluded. Services unded by state general unds targeted the latter group, but these resources shrank as states contended with budget problems.
Troughout the modern history o public psychiatry, populations have been identified as the special responsibility o the state, either as a last resort or to protect society. Although many special populations contained a number o people with SMIs or SUDs, the responsibility o public psychiatry or its core target population was ofen diluted. Despite these variations in target population definition, the central challenge or the public system o services is still to remain true to the core population o people with severe, persistent, and disabling behavioral disorders.
I S TH E RE A S YS TE M O F P UBL I C P S YC H I ATRY?
Despite its apparent disorganization, there is indeed a public psychiatry service system. Te current service system is a historical overlay o service and support components laid down over many years, in successive periods o development. Te system or SUDs has distinct historical roots and is
ofen orthogonal to mental health services, although many services or co-occurring disorders exist. Te system also is stratified at ederal, state, and local levels. Te US Substance Abuse and Mental Health Services Administration (SAMHSA) and state departments o behavioral health define the purpose and unction o the system through policies, demonstration projects, and the financing o ser-
vices. County and local stratifications o management also contribute to the policies, services, supports, and financing o the system. Te mission o serving people with SMIs and/or SUDs unites these parts o the system. Evaluation, treatment, case management, early intervention, outreach to people who are homeless, psychosocial rehabilitation including work and educational supports, other community supports such as housing, integrations with primary care, orensic consultation, peer-run programs, and prevention o behavioral disorders make up the current system o public psychiatry. A ull spectrum o mental health and
addiction proessionals, community-based specialists, and program managers work through IDs within this system. Federal, state, and local sources finance the services, community supports, and personnel that make up the system. On a local level, the system comprises a variety o organizations: community mental health centers, ederally qualified community health (primary care) centers, general hospitals, emergency rooms, state-operated agencies, and private nonprofit agencies provide treatment, rehabilitation, and community supports. Each o these has particular policies, budgets, and a program o services and/or supports that they manage.
As a result o the broad array o services and supports, their disparate sources, and the historically piece-meal development o the current system (see Chapter 2), the service system o public psychiatry is complex, disjointed, and difficult to navigate. o understand it ully requires effort studying it and time working in it. Working on the most basic level o the system, the proessional in public psychiatry marshals the multiple elements o the system into individual plans o care or people with SMI and/or addiction. Tis process is the strongest source o cohesion currently available or making the system work effectively or people
who need care. Chapter 2 fleshes out this starting definition o the
service system o public psychiatry with a more detailed description, provides a brie history o its development as a strategy or understanding it, and amplifies a discussion o its financing. Subsequent chapters in this textbook elabo- rate on public health, substance abuse services, primary care, recovery and social inclusion, orensic services, and other parts o the system.
Tis definition o the system is universal and generic or the United States. However, below the ederal level, considerable variation exists among state authorities or mental health and addiction services, not to mention state Medicaid programs. At the local, county, and city level, considerably more variation exists rom place to place depending on state policies and local agency initiatives and development. Te
array o services available in each locale is a unction o all o these levels. At a local level, a description o the system becomes particular and concrete. Still, the particulars o one place (such as New Haven, Connecticut, in the case o this textbook) illustrate useully the outline o the system in many locations.
Te bottom line or the service system is the array o clinical programs and community supports it provides or people with SMIs and/or SUDs, thereby enabling person- centered, individualized plans o care. A key value o this textbook is that it emphasizes that a system ought to incor-
porate as ull a range o services and supports as possible. Inthis regard, several aspects o the system, including rehabilitative community support, public health, integrated health care, and services or co-occurring disorders and chronic addictions, deserve special emphasis because they have ofen been given short shrif i not ignored on the clinical side. Subsequent chapters will give ull consideration to these parts o the system.
C L I N I C AL C O MP E TE N C E I N P UBL I C P S YC H I ATRY
Proessionals in public psychiatry must acquire expertise in caring or people with SMIs and SUDs, the central target population. Psychopharmacologic and psychotherapeutic expertise and psychiatric consultation skills are cornerstones, but they must be supplemented by additional knowledge and skills in the areas o rehabilitation, accommodation, navigation, and the provision o in vivo supports in various lie domains affected by these conditions.
Psychopathology or the proessional in public psy-
chiatry is more than knowledge o the disorders listed and defined in the Diagnostic and Statistical Manual, Fih Edition (DSM 5)6 In public psychiatry, the clinical picture is larger and all-encompassing. In the public sector, more so than in other domains o practice, psychiatric disorders defined by DSM5 are associated not only with morbidity caused by relapses, but also with mortality (suicide and pre- mature death rom a variety o causes) and impairment in unctioning (disability or burden o disease). It is essential
or the proessional in public psychiatry to attend to all these aspects o illness and their interrelationships. Accordingly, this textbook addresses the entire course o illness, all o its outcomes, and the competencies needed to be effective in practice.
Furthermore, clinical competence in public psychiatry involves mastery o this complex clinical picture as part o
an ID o caregivers in different settings, not just in the hospital and clinic. Tese include residential settings, the street, rehab centers, legal offices, and homeless shelters. Not only must public psychiatry proessionals learn to practice in all these settings, they must be savvy about the system in which they work in order to mobilize it or the people they care or. In contemporary public practice, a supported apart- ment or other residential setting, as opposed to a hospital, is ofen the platorm or arranging care. Tese are the settings in which proessionals practice without the “white coat” o the hospital setting. Te key or making public services
work or individuals with SMI and SUDs is the practicing proessional in public psychiatry who works as part o, and ofen leads, an ID that creates personal, comprehensive, coherent, recovery-oriented, and integrated plans o care in the community while using the hospital, emergency room, and other alternatives (such as respite care) or backup in the case o acute crises.
Furthermore, it is not sufficient or educators and practicing proessionals in public psychiatry to assure them- selves that their practice is competent. It is also necessary to measure key process and outcome indicators in the various domains o practice in order to document and then strive to improve the quality o care. uality data, together with the cost o services, are two actors in an equation o value (with value equaling the ratio o quality over cost). uality measures are useul not only or monitoring and improv- ing outcomes, but also or reporting transparently about the quality o services. In each domain o practice covered in this textbook, such as treatments or SUDs, ambulatory treatment or major disorders, or assertive community treatment, the authors provide a discussion o key quality metrics in that area. A humble attitude o continually striv- ing or improvement, in contrast to assertions o proession-
alism and even perection, is the oundation or achieving quality care. Attention to quality metrics, along with independent learning, provides a building block or ongoing clinical competence in the uture.
While maintaining a ocus on person-centered clinical competence or the proessional, the authors o this textbook also assume that many public psychiatry proessionals will advance in their careers into positions o leadership. Te content, integration, and comprehensiveness
o the didactics in this textbook are a oundation not only or clinical competence but also or effective leadership in the field. Te best leaders will need clinical competence; a comprehensive, integrated, interdisciplinary understanding o the field o public psychiatry; and well-honed management skills.
IS PUBLIC PSYCHIATRY A S UB S P E C I A LT Y
O F G E N E RAL P S YC H I ATRY?
Predicated on the logic developed so ar, it is important to recognize that public psychiatry is an important subspe- cialty o the general mental health proessions. Advanced education in public psychiatry builds on general education in the mental health proessions. In general education, the proessional student learns interviewing, diagnosis, psycho-
therapies, psychopharmacology, consultation, and otheraspects o practice in hospital, clinical, and community settings. Advanced education in public psychiatry builds on these oundational skills and addresses the knowledge and practice defined earlier.
At present, public psychiatry is not officially a subspe- cialty o psychiatry. In the past 20 years, however, several groups have made the case or such certified training.1,3,7 Tere is a special body o knowledge to master and proessional organizations to support such specialists, and the development o certified education programs would fill an existing need, improve educational quality, and offer a bridge to the uture. Within the context o current health care reorm and as a result o other actors shaping practice in public psychiatry, it is all the more important to have dedicated, specialized, and certified proessionals in public psychiatry.
Tere is no doubt that public psychiatry makes important contributions to academic departments o psychiatry. In a previous volume, the authors considered the contributions to public psychiatry o academic programs at the Connecticut Mental Health Center o the Yale Department o Psychiatry 8 (see Chapter 19 or a more detailed discus-
sion o this idea). Te establishment o advanced qualifications in public psychiatry would enhance these academic pursuits. Also, advanced qualifications would support and consolidate a cadre o academic proessionals who are needed to move the field o public psychiatry orward in teaching and research departments o psychiatry during a time o great change. Reflecting this need, the American Association o Community Psychiatrists began certifica- tion o advanced credentials in public psychiatry in 2015.
W H AT A R E T H E E D UC AT I O N A L P R I N C I P L E S O F T H I S T E X T B O O K ?
Te editors and authors have imbued this textbook with their shared belies and commitments to a comprehensive curriculum in public psychiatry. Shared educational principles and philosophy guide the content, and an education
structure made up o multiple interrelated parts offers many platorms or educational experiences. Tis textbook con- tains the core didactics or teaching the care o people with SMIs and co-occurring or independent SUDs. In addition, the didactics are supplemented with selected, current citations in the literature, reflected in the bibliographies or each chapter.
Te educational principles o this textbook derive rom the authors’ shared conviction in and commitment to a publicly unded system o service delivery. Optimal service delivery in the system o public psychiatry is char-
acterized as a ull range o services (1) provided by IDsmade up o proessionals and specialists; (2) inormed by an understanding, derived rom public health, o the local community and its population; (3) based in the community; (4) person-centered; (5) recovery-oriented; (6) culturally competent; (7) integrated with primary care, addiction medicine, public health, and orensic psychiatry; (8) evidence-based; (9) competency-based (through training); and (10) driven by consumer and amily satisaction as part o quality improvement. Te educational principles apply to the eatures o the service system defined and itemized earlier, and the organization o the textbook cor- responds largely to the typology o the system and the educational principles presented earlier.
It is important to emphasize that the curriculum offered in this textbook is predicated on the assumption that the proessional student already has accomplished basic clinical and proessional education in interviewing, evaluation, diagnosis, ormulation, treatment, and rehabilitation. Assuring this premise is a unction o screening and selec- tion o candidates or advanced education in public psychiatry. Tis principle does not exclude the possibility that selected chapters rom the textbook can be used as an intro-
ductory module in public psychiatry or beginning proessional students.
Second, this textbook is interdisciplinary in editing, authorship, content, consideration o roles, and teaching. It is not designed or just one proessional group. Te interdisciplinary character o the textbook reflects a conviction that practice in public psychiatry ought to be accomplished through IDs. Psychiatrists, psychologists, nurses, social workers, rehabilitation therapists, and peer staff bring
special skills to the task o caring or people with SMI and addictions. Working together effectively as a team is a proessional skill in itsel.
Also, the textbook teaches an integrated approach to the practice o public psychiatry. Te text integrates the diverse parts o a complex public system with the comple- mentary clinical, rehabilitative, and support tasks o care in
the community. It integrates both public health and clinical perspectives. It addresses the integration o public psychiatry and primary care through medical homes, and it also emphasizes the challenge o integrating psychiatry and addiction medicine. Te text strives or integration in order to (1) achieve a complete picture o psychiatric and SUDs in the community where they occur, (2) understand the continuum o practice rom prevention and early intervention through treatment o acute illness and relapse prevention to finally easing the burden o disease while supporting recovery and citizenship, and (3) have an appreciation o
how public psychiatry can help meet the challenges com-munities ace, such as untreated illness, suicide, violence, addictions, and burden o disease.
Furthermore, this textbook emphasizes clinical competence in the educational program. In this textbook, clinical competence is undamentally person-centered and ocused on people with SMIs and SUDs in a variety o settings. Although the human encounter is essentially the same in all o psychiatric practice, the clinical relationship varies in a population o largely poor, culturally diverse people with limited educational opportunities and long-term disabilities. Beyond that, the setting o practice in public psychiatry is not just the short-term hospital, clinic, or emergency room but also the residential program, the street corner, the home, the homeless shelter, the laundromat, and the court- house. Clinical competence includes not only up-to-date knowledge but also a commitment to continue to learn and to strive or the highest quality o service using transparently reported quality metrics. An educational program requires a curriculum that is designed to meet the various needs o people cared or in public practice, in the settings in which they are encountered, with the highest quality o care.
In addition, this textbook has universal application.
Although rooted in a particular institution o an academic department o psychiatry in a particular city and state, the educational program embodied here prepares students or success in public psychiatry anywhere in the United States. Needless to say, the target population o people with SMIs and/or SUDs share common eatures regardless o setting. Also, the American service system, although varying rom state to state and location to location, shares undamental eatures. It is or these reasons that the educational content
o the textbook is applicable in any setting, any system, and any educational program within the United States.
Finally, this textbook reflects an educational conviction that a system or public psychiatry ought to incorpo- rate a ull range o community-based services: acute and long-term clinical, rehabilitation, primary care, addiction, public health, and orensic services and community-based
supports. Perhaps the rehabilitative, community support, and public health aspects o the system deserve special emphasis because they are sometimes given short shrif. Rehabilitative programs address disability, including psy- chological, social, and cognitive approaches. Community- based support ocuses on increasing persons’ access to housing, jobs, school, aith communities, and other natu- rally occurring community activities. Public health components o the system include programs or prevention o substance abuse, early intervention in the course o illness, programs to establish and maintain wellness, attention and
amelioration o health disparities among subpopulations,and commitment to maintaining a population perspective in the development o the system and the allocation o resources.
As educators, the authors aim to kindle a flame o learning while beginning to fill gaps in existing knowledge. Tey aspire to spark a lielong commitment to independent study through reading the literature and using independent judgment about new data. As a starting point, the bibliographies in each chapter offer an entry into the literature. Small seminars in the local ellowship program in public psychiatry are designed to encourage critical thinking and discussion. Students are encouraged to evaluate new evidence and to conduct independent research, with a goal o achieving up-to-date, evidence-based practice throughout a career in public psychiatry. In addition to small seminars, the optimal pedagogical structure includes personal and clinic-based supervision and the creation o a community o curious, science-oriented, public proessionals, all o which support this aim. In Chapter 16, a discussion o discipline- based and interdisciplinary teaching o public psychiatry resumes with respect to the elements o education and the important issue o workorce development.
W H AT I S T H E VI S I O N F O R T H I S T E X T B O O K ?
Te authors’ vision is to contribute through scholarship and teaching to the best possible education in public psychiatry. Using this textbook, the editors’ and authors’ aim is to prepare advanced proessional students as outstanding
clinicians, as leaders, and, in some cases, as scholars. Te goal is to equip them with up-to-date, clinical, person- centered knowledge and practice within a public service system. Given that the service system is broad, extensive, and complex, the authors believe that the most powerul orce or the integration o services and supports is the well-educated, individual proessional in public psychia-
try. It is the proessional clinician and leader— properly and well educated in caring or people with SMIs and/or SUDs; capable o advanced clinical practice in the public sector; knowledgeable in the value o residential and community supports; prepared or integrated health care, addiction medicine, public health, and orensic psychiatry; and expert in recovery— who connects the disparate parts o the system into a plan o care on behal o and in collaboration with individuals living with SMIs and/ or SUDs and their amilies. Te quality o care derives rom the incorporation o all these elements into a com-
prehensive, integrated, systemic, person-centered clinical process.
TH E O RG AN I Z ATI O N AN D C O N TE N T O F T H I S T E X T B O O K
Tis textbook can be seen as a summary o the didactics in a curriculum or public psychiatry. Each chapter, alone or in combination, supplemented by citations rom the literature, might serve as a oundation reerence or a seminar in a series that provides advanced, proessional education in public psychiatry. Selected chapters can serve as the elements o a brie module in public psychiatry or beginning proessional students (e.g., the Introduction, Systems, Public Health, Recovery, and the Conclusion).
Te textbook has 19 chapters organized into our parts. Chapter 1 introduces the textbook, and Chapter 19 con- cludes it. Te our parts in between are Part I “Te Service System o Public Psychiatry, Part II “System Integration Challenges in Public Psychiatry, Part III “Te Services and Clinical Competencies o Public Psychiatry,” and Part IV “System Development in Public Psychiatry.” When
appropriate, the chapters offer brie histories o their topic. Most chapters consider quality metrics applicable to their domain, and most chapters cross-reerence other chapters to emphasize overlapping and integrative themes. Some o the chapters use case examples to illustrate content. Each chapter includes an opening box summarizing the educational highlights o the chapter. Finally, each chapter has a selected bibliography to serve as an entry into the literature or the purposes o in-depth sel-education.
Part I, “Te Service System o Public Psychiatry,” con- tains three chapters. Te service system is a distinguishing eature o public psychiatry. Chapter 2 offers three perspectives on this complex service system: (1) historical and developmental, (2) descriptive and structural, and (3) economic. It reviews the status o the “de acto” system, the management o the system, the tendency or skewed system
development, and system transormation. Te chapter iden- tifies the ID as the undamental unit o service in the system. Te system is an essential constellation o resources and a context or practice in public psychiatry. Chapter 2 covers not only proessional and scientific initiatives but also polit- ical and economic policies that shape the service system.
Chapter 3 on recovery begins with a brie history o the recovery movement in psychiatry. Recovery is now one o the basic assumptions o public psychiatry. Tis chapter covers three major implications o recovery: (1) the provision o person-centered care, (2) the development
o peer- provided supports, and (3) involvement o peersin assessments o quality and health care outcomes. Te “discovery” o recovery is one o the most important developments in public psychiatry in the past 50 years. Te undamental process o person-centered care planning creates a ramework or integrating clinical care o symptoms, rehabilitation, and living in the community while responding to the goals and priorities o the person seeking help. It goes beyond symptom reduction to social inclusion and integration into society.
Chapter 4 covers the crucial importance o community supports or practice outside the walls o the hospital. It emphasizes the value o the social inclusion o people with SMIs and addictions in recovery. It covers residential services, supported employment, supported education, and the techniques o psychosocial rehabilitation. It considers the need or all proessionals in public psychiatry to integrate clinical care, community supports, and psychosocial rehabilitation within a ramework o person-centered care. It takes a “village” committed to community-based integrated care and social inclusion to establish an optimal system o services.
Part II, “System Integration Challenges,” includes our
chapters regarding our major integrative tasks currently acing the service system o public psychiatry: (1) integrated health care, (2) addiction medicine, (3) public health, and (4) orensic psychiatry. “Integration to the ourth power” is an expression that captures the exponential challenge ahead. Ultimately, the integration o plans o care or individuals seeking service is the most undamental goal.
Chapter 5 addresses integrated health care and wellness as the latest expression o mainstreaming in public psychiatry,
a concept originating in the health policy debates o 1993. Most o the shortened lie expectancy o people with SMIs and addictions is related to chronic conditions such as dia- betes mellitus, hypertension, cancer, and inectious diseases. Tis chapter considers the models, levels, and principles o integrated health care. It discusses medical homes, behavioral health homes, and the impetus given to integrated care
by the Affordable Care Act (ACA). Chapter 6 advocates or a greater integration o addic-
tion medicine into public psychiatry and the leadership to carry this out. Te chapter considers the service system o addiction medicine; the neurobiology and environ- mental actors in addiction; diagnosis, pharmacologic, and psychotherapeutic treatments; and dispositions or continuing care. It covers the evaluation and treatment o co-occurring disorders, and it argues or ull equity o addiction services with mental health and primary care services. Te ACA presents an opportunity to achieve bet-
ter integration o addiction medicine into medicine and psychiatry, and public psychiatry may be instrumental in making this happen.
Chapter 7 argues that the incorporation o public health and population perspectives into public psychiatry is yet another key integrative task. Te chapter provides definitions o key concepts in psychiatric public health. It illustrates how public health data on morbidity, mortality, and disability can inorm psychiatric practice. Public health interventions, or prevention, when integrated into practice, offer an amplified spectrum o practices and acilitate adaptation to new models o practice-based population health. An ounce o prevention in public psychiatry has the poten- tial to better balance the service system through enabling reallocation o finite resources to reaching as many people in need o services as possible.
Chapter 8 discusses how the interdigitation o orensic psychiatry and public psychiatry supports essential skills and competencies that need to be integrated into public practice. Many people with SMIs and SUDs have legal problems. Forensic psychiatry has grown, especially in the era o deinstitutionalization, as a large, independent sub- specialty to address these issues. Forensic psychiatry pro-
vides expertise to the public proessional regarding special orensic hospitals, oversight o orensic populations, orensic community services, risk assessment, and collaborations with court, probation, and parole officers.
Part III, “Te Services and Clinical Competencies o Public Psychiatry,” describes the services and competencies that are essential or public practice. Te topics covered are (1) children, adolescent, and young adult services, (2) early intervention or psychosis, (3) hospital services,
(4) ambulatory services, (5) outreach services and services or special populations, (6) cultural competency, and (7) global mental health.
Chapter 9 reviews the public system or children, adolescents, and young adults, where a developmental perspective is essential or clinical practice and services. It covers a spectrum o special treatment considerations or these
target populations. Youth who are transitioning out o the child system and into adult services, many o whom are already chronically ill and disabled, are particularly difficult to care or in the community. Te chapter considers the challenges acing the child-ocused system, including the long-standing need or better integration with the adult- ocused system and the need or more manpower.
Chapter 10 presents early intervention programs or psychosis; these are probably the most important program developments in contemporary public psychiatry. Tese interventions, which distantly echo ideas about
community-based crisis intervention that were part o thelaunch o community mental health in the 1960s, shif the ocus o public practice rom the end stages o persistent illness and disability to strategies or prevention o disability. Chapter 10 reviews the timing o interventions and first- episode services or the purpose reducing the duration o untreated psychosis. As evidence accumulates and the service system tools up, early intervention is potentially game- changing or the service system o public psychiatry.
Chapter 11 presents clinical services in hospitals. It covers acute care in emergency rooms and on inpatient units o general hospitals and long-term care in state hospitals, including orensic programs. It also reviews partial hospi- talization. It elaborates on the ID in the hospital setting, where team unctions are codified in accreditation require- ments, hospital departments, and procedures. Skill in working on an ID is a core competency or proessionals in public psychiatry, differentiates them rom solo practitio- ners in psychiatry, and supports this undamental unit or the delivery o services in the system. Finally, this chapter discusses the hospital as a microcosm in which system variables play out.
Chapter 12 reviews ambulatory services in both com-
munity mental health centers and ederally qualified community health centers. It breaks down ambulatory services into walk-in, continuing care, transitional care in and out o hospitals, and specialty programs. A broad, truly bio- psychosocial, clinical consciousness underlies the clinical competencies considered in this chapter. Proessionals in public psychiatry are the transducers o the system or a person seeking services. Trough creative and proessional plans o care, the proessional in public psychiatry
helps to pull the system o services together or the person with SMI and/or SUDs. It is the personal encounter and the cohesion, management, and adaptation o person- centered plans o care or individuals developed by the individual clinician that lies at the heart o practice in public psychiatry.
Chapter 13 presents special outreach services and
services or special populations. Tese include homeless outreach; assertive community treatment; residential treatment programs; programs or those with traumatic brain injury; lesbian, gay, trans-sexual, and transgender services; veterans’ services; and elderly services. When public proessionals enter many o these domains, the white coat o the hospital usually is lef behind and different rules o engage- ment and competencies are necessary. Te chapter discusses clinical competencies in each o these domains.
Chapter 14 describes the cultural competence necessary or proessionals in public psychiatry to engage effectively
and sustain in treatment people o diverse backgrounds.Cultural competence figures prominently in strategies or reducing disparities in the treatment outcomes or people rom cultural or ethnic minorities. Te chapter reviews special evaluation modules and general education as undamental strategies or preparing behavioral proessionals to serve a wide range o populations. Person-centered care is a template or cultural competency. Cultural curiosity can be a lielong pursuit that not only enhances practice but also can lead to considerable personal growth.
Chapter 15 introduces the burgeoning area o global mental health. Public psychiatry can be a pathway to global mental health and international practice. Tis chapter discusses the right to treatment and the need or psychiatry to have an international perspective. Te challenge o meeting the needs o vulnerable populations such as reugees and recent immigrants brings home lessons learned in international practice. Te development o telemedicine in low- resource settings may have applications in rural settings at home or or special populations. Tese examples suggest a useul, reciprocal relationship between global mental health and public psychiatry.
Part IV, “System Development in Public Psychiatry,” has
three chapters ocusing on education and workorce development, evidence-based practice, and administrative best practices or the service system.
Chapter 16 discusses interdisciplinary teaching o proessionals in public psychiatry with an eye to workorce development. It describes the elements o teaching programs in public psychiatry, both as part o core, discipline-based education and also in advanced ellowships, using the Yale Department o Psychiatry as
an example. It emphasizes the value o interdisciplinary learning in advanced education programs, which are needed to address the inadequacies o core preparation. Only by attending to preparatory and continuing education in public psychiatry is it possible to adequately meet the field’s uture workorce needs.
Chapter 17 on evidence-based practice addresses
another basic strategy or system development. New dis- coveries, the evaluation o services, and their translation into evidence-based practices move public psychiatry orward. Tis chapter emphasizes the need or training and fidelity monitoring and discusses challenges in implementation, as well as implementation strategies. It reviews the use o technology to achieve the goal o evidence-based practice. Tese topics are essential knowledge or scientist- proessionals who aspire to evidence-based practice in the public system.
Chapter 18 considers administrative best practices in
public psychiatry. Te service system is only as good asits management at all levels, rom the clinical team leader to the chie executive officer. Tis chapter is predicated on this axiom and describes how to get the best out o the system and those who work in it. Trough a variety o measures within the context o recovery-oriented, person-centered care, and practice-based population health, creative and effective management provides ongoing stewardship or and development o the system. Acknowledging that “leadership is a relay race” current leaders must teach leadership to their junior colleagues, who in turn must develop and plan or their personal development as leaders.
Chapter 19 describes how the system o public psychiatry is in a state o flux. It discusses the major policies and variables that are driving development in the system, including insurance reorm, new service delivery models, and variables reshaping practice. It suggests that public– academic partnerships can be powerul alliances or developing and sustaining the system. It also suggests that academic divisions o public psychiatry in departments o psychiatry are instrumental in achieving uture development in the field.
TH E S I G N I FI C AN C E O F P UBL I C PSYCHIATRY
Public psychiatry is the saety net o services or people with severe and persistent mental illnesses and SUDs. Ultimately, the signiicance o public psychiatry is
ound in the changed lives and hopeul utures o these people who are successully supported as they recover in the public system. ake, or example, a young student whose lie is disrupted by acute psychosis and who is successully treated, receives cognitive training, and is supported by the psychoeducation o his or her amily, thus paving the way or recovery rather than a lietime
o chronic illness. Or consider a single mother, threat- ened with the loss o her children unless her psychotic depression is treated. With successul treatment o her depression and delusions, and while attending a support group or young mothers, she is able to organize her daily lie, establish a stable place to live, and care consistently or her children. Or consider a woman with an addiction who is precariously holding on to a job that her whole amily depends on. With treatment, she can attend work regularly and productively. Although not all interventions in public psychiatry are ully success-
ul, and there is much to learn and improve, these ewexamples illustrate the crucial value o public practice in the lives o those it serves.
It is possible and important to conceptualize the significance o public psychiatry not only or the individual, but also or the community. Recent tragic events involv- ing gun violence and public health problems in American society dramatize the challenges to be addressed. Public psychiatry, among other proessional disciplines, has a role to play in solving these challenges, and education in public psychiatry supports this role. Integration o knowledge and practice in public psychiatry is critical in addressing the challenges o isolated, young adults alling into psychosis or o suicide among young adults and military veterans. Public health strategies and the public system o care help to trans- orm psychiatric practice so that it ocuses more on prevention, when possible, and early intervention to address these problems.
Another perspective on the significance o public psychiatry is the enormous size o the enterprise. In 2009, about hal o all mental health and substance abuse expen- ditures were in the arena o public psychiatry (combined cost to Medicaid, state agencies, Social Security Disability
Insurance, and ederal block grants; see Chapter 2, Figures 2.1 and 2.2). According to data rom the Surgeon General’s 1999 report on mental health, 2% o the American population received care that year in the public sector, out o the 15% o the population receiving mental health care.9 Although larger in comparison with other proessional groups, 40% o psychiatrists work ull or part time in the public sector. Under the auspices o the ACA, the number
o behavioral proessionals and the entire enterprise will continue to grow because public psychiatry plays a key role in managing the vast increase in access to services through Medicaid or behavioral disorders.
S U M M A R Y
Tis textbook strives or excellent, comprehensive, integrated, advanced, proessional education in public psychiatry. Tis chapter introduces the textbook by providing definitions o public psychiatry, the target population o people with SMIs and co-occurring or independent SUDs, and the service system. It discusses the special clinical competencies o public practice, and it reviews the educational principles that guide the book’s various chapters while pre- senting the book’s organization and content. Te authors conclude that the present is a time o great significance or
public psychiatry, given its critical role in the lives o people with serious, persistent behavioral disorders and disabilities; its size as part o the behavioral health care enterprise; and its expansion under health care reorm.
R E F E R E N C E S
1. Brown DB, Goldman CR, Tompson KS, Cutler DL. raining psychiatrists or community

yale textbook of public psychiatry.1e.2016.unitedvrg.htd

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