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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
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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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1 Oxord University Press is a department o the University o Oxord.
It urthers the University’s objective o excellence in research,
scholarship, and education
by publishing worldwide.Oxord is a reg istered trade mark o Oxord
University Press in the UK and certain other countries.
Published in the United States o America by Oxord University
Press
198 Madison Avenue, New York, NY 10016, United States o
America.
© Oxord University Press 2016
First Edition published in 2016
All rights reserved. No part o this publication may be reproduced,
stored in a retrieval system, or transmitted, in any orm or by any
means, without the
prior permission in writing o Oxord University Press, or as
expressly permitted by law, by license, or under terms agreed with
the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the
scope o the above should be sent to the Rig hts Department, Oxord
University Press, at the
address above.
You must not circulate this work in any other orm and you must
impose this same condition on any acquirer.
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
o the drug dosages mentioned in the material. Te authors and the
publisher do not accept, and expressly disclaim, any responsibility
or any liability, loss or risk that may be claimed or incurred as a
consequence o the use and/or application o any o the contents o
this material.
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To people recovering fom serious mental illnesses and substance use
disorders and to those who serve them
through clinical services, education, and research.
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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
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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
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ix
FOREWORD
he emergence o this important textbook on pub- lic 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 pub- lic psychiatry whose
research identified significant dispari- ties in mental health
treatments available to patients rom upper socioeconomic groups
compared with those availa- ble 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 pub- lic
psychiatry as an academic discipline with prominence in the
Department equal to that o biological and psy-
chological research. In 1957, Dr. Redlich began pioneer- ing
discussions with Abraham Ribicoff, then Governor o Connecticut,
about the creation o a public psychiatry insti- tute to address
mental health disparities. Afer President Kennedy signed the
Community Mental Health Center Act in 1963, Dr. Redlich implemented
these plans with ed- eral 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 perspec- tives are included
in service development and delivery, pre- vention 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 pro- vides
an opportunity to explore integrated medical and psy- chiatric care
and wellness or indigent people with serious mental illnesses
and/or addictions.
Although the CMHC was ounded to promote a pub- lic 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 psycho-
social 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 con- tinuum 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 pre-
viously 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 out- standing training
to students o the health proessions. Medical students and
psychiatric residents have opportu- nities to work on
interdisciplinary teams caring or highly stigmatized, vulnerable
patients, alongside nursing, psy- chology, and social work
trainees. Community mental
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x • F O RE W O RD
health workers, some o whom are also consumers o men- tal health
care, provide an important recovery-oriented per- spective 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 psychoso- cial
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 mis- sion 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
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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 educa- tional
programs o proessional students. It is guided by uni-
fied educational aims, a shared teaching philosophy, and
anintegrated perspective (public psychiatry in relation to pri-
mary care, addiction medicine, public health, and orensic
psychiatry) with regard to the service system and practices o
public psychiatry. It emphasizes the competencies neces- sary 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 inter- disciplinary 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
descrip- tion 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 sup- port 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 ill- nesses and substance use disorders, a
discussion o the serv- ice 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 expan- sion. 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 aca- demic
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 psychia- try 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.
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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 com- munity supports
available to them.
Although the editors and authors have done their utmost to provide
a comprehensive introduction to cur- rent, 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 possibil- ity. 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
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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.
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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
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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
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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
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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
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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
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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 educa- tion (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 psy- chiatry 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 psychia- try 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: pub- lic
psychiatry is that part o the practice o psychiatry that is (1)
financed by the general unds o state departments
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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 eli- gibility determined by
the Social Security Administration. In addition, the US Department
o Housing and Urban Development supports residential services.
Public psychia- try 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, commu- nity 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 set- tings. 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 psy-
chiatry 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, evaluat- ing,
implementing, and managing services.
Tis definition o public psychiatry incorporates ele- ments 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 admin- istrative. 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 pub- lic psychiatry. Te VA is
sufficiently distinct as a national health service or veterans that
it deserves separate consid- eration. 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 ser- vices research.
Indeed, some veterans move back and orth between the systems and
differ in their preerences or pub- lic 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; sub- sequent chapters address
clinical competence, and addi- tional 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 psychi- atry 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 stud- ies 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
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I N T R O DU CT I O N • 3
earlier, public psychiatry also cares or special popula- tions,
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 pop- ulation
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 recur-
rent 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 citi- zenship 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 psy- chiatry 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 bud- get problems.
Troughout the modern history o public psychiatry, populations
have been identified as the special respon- sibility 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 responsibil- ity o public psychiatry or its core target
population was ofen diluted. Despite these variations in target
popula- tion 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 pub- lic
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
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4 • I N T R O DU CT I O N
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 commu- nity supports such as housing, integrations
with primary care, orensic consultation, peer-run programs, and
preven- tion 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, com- munity
supports, and personnel that make up the system. On a local level,
the system comprises a variety o organiza- tions: community mental
health centers, ederally qualified community health (primary care)
centers, general hospi- tals, 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 ser- vice 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 psychia- try marshals the multiple elements o
the system into indi- vidual 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, con- siderable 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 rehabili-
tative 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 psycho- therapeutic expertise and
psychiatric consultation skills are cornerstones, but they must be
supplemented by additional knowledge and skills in the areas o
rehabili- tation, 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
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I N T R O DU CT I O N • 5
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 hos-
pital 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 prac- ticing
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, ambula- tory 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 inde- pendent
learning, provides a building block or ongoing clinical competence
in the uture.
While maintaining a ocus on person-centered clini- cal
competence or the proessional, the authors o this textbook also
assume that many public psychiatry proes- sionals will advance in
their careers into positions o lead- ership. 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 manage- ment 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 set- tings. 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 proes- sional 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 impor- tant
contributions to academic departments o psychiatry. In a previous
volume, the authors considered the contri- butions 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 qualifica- tions 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.
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6 • I N T R O DU CT I O N
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 prin- ciples 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 cita- tions 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 commu- nity; (4) person-centered; (5)
recovery-oriented; (6) cul- turally competent; (7) integrated with
primary care, addiction medicine, public health, and orensic
psychiatry; (8) evidence-based; (9) competency-based (through
train- ing); 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 edu- cational 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 clini- cal and proessional
education in interviewing, evalua- tion, diagnosis, ormulation,
treatment, and rehabilitation. Assuring this premise is a unction o
screening and selec- tion o candidates or advanced education in
public psy- chiatry. 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 proes- sional
students.
Second, this textbook is interdisciplinary in editing, authorship,
content, consideration o roles, and teach- ing. It is not designed
or just one proessional group. Te interdisciplinary character o the
textbook reflects a convic- tion that practice in public psychiatry
ought to be accom- plished 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 pro-
essional 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 clini- cal
perspectives. It addresses the integration o public psy- chiatry
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
interven- tion through treatment o acute illness and relapse
preven- tion 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 compe- tence 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
disabili- ties. Beyond that, the setting o practice in public
psychia- try 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
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I N T R O DU CT I O N • 7
o the textbook is applicable in any setting, any system, and any
educational program within the United States.
Finally, this textbook reflects an educational convic- tion 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 com-
ponents 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 perspec- tive in the
development o the system and the allocation o resources.
As educators, the authors aim to kindle a flame o learn- ing 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 bibliog- raphies 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 evi- dence 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 psy- chiatry.
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 pub- lic sector; knowledgeable in
the value o residential and community supports; prepared or
integrated health care, addiction medicine, public health, and
orensic psychia- try; 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 litera- ture, 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 begin- ning 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 educa- tional 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.
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8 • I N T R O DU CT I O N
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 per- spectives on this complex
service system: (1) historical and developmental, (2) descriptive
and structural, and (3) eco- nomic. 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 sys- tem. 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 chap- ter 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 devel- opments in public
psychiatry in the past 50 years. Te un- damental process o
person-centered care planning creates a ramework or integrating
clinical care o symptoms, reha- bilitation, 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 integra- tion 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 ser- vices, 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 reha- bilitation 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 ac- ing
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, behav- ioral 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 adap- tation 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 pub- lic 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, oren- sic
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 competen- cies that are
essential or public practice. Te topics cov- ered are (1) children,
adolescent, and young adult services, (2) early intervention or
psychosis, (3) hospital services,
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I N T R O DU CT I O N • 9
(4) ambulatory services, (5) outreach services and ser- vices
or special populations, (6) cultural competency, and (7) global
mental health.
Chapter 9 reviews the public system or children, ado- lescents, and
young adults, where a developmental perspec- tive 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 pro- gram 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 ill- ness 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 ser- vice system tools up, early
intervention is potentially game- changing or the service system o
public psychiatry.
Chapter 11 presents clinical services in hospitals. It cov- ers
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 work- ing 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 vari-
ables play out.
Chapter 12 reviews ambulatory services in both com-
munity mental health centers and ederally qualified com- munity
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 proes- sional plans o care, the proessional in
public psychiatry
helps to pull the system o services together or the per- son 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 treat- ment programs;
programs or those with traumatic brain injury; lesbian, gay,
trans-sexual, and transgender services; veterans’ services;
and elderly services. When public proes- sionals 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 unda- mental 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 dis- cusses 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 interna- tional 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 devel- opment,
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 work- orce
development. It describes the elements o teach- ing programs in
public psychiatry, both as part o core, discipline-based education
and also in advanced el- lowships, using the Yale Department o
Psychiatry as
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10 • I N T R O DU CT I O N
an example. It emphasizes the value o interdisciplin- ary learning
in advanced education programs, which are needed to address the
inadequacies o core preparation. Only by attending to preparatory
and continuing educa- tion 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 or- ward. Tis
chapter emphasizes the need or training and fidelity monitoring and
discusses challenges in implemen- tation, 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 ongo-
ing 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 psy- chiatry 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 develop- ment
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 sup- port 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 sig- nificance 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 chal- lenges 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
preven- tion, when possible, and early intervention to address
these problems.
Another perspective on the significance o public psy- chiatry 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
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I N T R O DU CT I O N • 11
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, inte- grated,
advanced, proessional education in public psy- chiatry. 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 com- petencies 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
disabili- ties; 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 psy-
chiatrists or community
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