Department of Psychiatry - spring 2022

Department of

PSYCHIATRY Psychiatry and primary care work together to identify and treat mental illness page 3

PHILANTHROPY

Thomas Marshall Foundation makes $1 million gift toward autism endowment page 4

INTERNATIONAL RESEARCH

CLOSING THE WORKFORCE GAP POSITIVE CLINICAL EXPERIENCES ENCOURAGE MORE MEDICAL STUDENTS TO GO INTO PSYCHIATRY PHOTO BY: MARK WASHBURN

INTEGRATING CARE

Spring 2022

Angie Lee, MED’22 (background, left) and Julie Frew, MD, MED’05, HS’06-10 discuss with Victoria Trump Redd, MD, D’14, HS’20-24 (foreground, left) and Olivia Fournier, MD, HS’18-22 what a career in psychiatry would look like.

Digital therapeutics improve healthcare in Colombia page 6

Interested in joining or supporting our team?

Find Department of Psychiatry employment opportunities at www.DHProviders.org.

Contact Megan Dodge in Medical and Healthcare Advancement at Megan.

Dodge@Hitchcock.org to learn more about opportunities to engage with and support our departmental activities.

Recognizing the nationwide need for skilled psychiatric health care providers, Dartmouth Health is working diligently to encourage Geisel School of Medicine medical students to pursue a career in psychiatry.

“Our job is to get medical students excited about psychiatry,” says Julie Frew, MD, MED’05, HS’06-10, vice chair for education in the Department of Psychiatry. “We do that by giving them positive experiences with faculty and in their rotations.”

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Department of Psychiatry

MESSAGE FROM OUR CHAIR PHOTO BY: MARK WASHBURN

INCREASING ACCESS TO CARE The Department of Psychiatry is fortunate to have the opportunity to make a meaningful positive impact on the lives of people locally, nationally and across the globe. People suffer badly from mental health and substance use disorders, and our work helps provide them relief.

The illnesses the department addresses are common, painful, often disabling, and sometimes deadly. Half of us in America will have a substance use or mental health disorder in our lifetime—20 percent in any given year.

Depression is the No. 1 disabling condition worldwide.

Almost all of us know people who have died by drug overdose or suicide, both of which are common causes of death in the United States. Psychiatric illnesses are very treatable, but currently, few people have access to timely, high-quality care.

Our department turns directly toward this challenge of increasing access to quality care through clinical care, workforce development and research. We offer outstanding services in our clinical sites and partner with the states of New Hampshire and Vermont to treat highneed populations. We leverage our knowledge to touch more lives by integrating psychiatric services in primary and specialty general medical services where people commonly seek care. We also increase access to quality care through expanding and improving the mental health workforce. We inspire, teach and train medical students, residents, psychologists, social workers and other master’s-prepared clinicians, psychiatric nurses and psychiatric nurse practitioners. Quality care is built on the foundation of science. Our research expands the knowledge and understanding both of the neuroscience

TOTAL FACULTY ACROSS ALL SITES

231

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including 11 full professors and 15 associate professors who are currently active

underpinnings of the illnesses and of the services that work to promote and support recovery.

Over the past several years as interim chair, I have been privileged to witness our faculty’s remarkable clinical and educational work at many locations: Geisel School of Medicine, Dartmouth Health, the White River Junction Veterans Administration Hospital, community mental health centers and throughout New Hampshire’s state care system, including New Hampshire Hospital. I have also witnessed the broad reach of our research. In this newsletter, we share a sampling of the work we do to care for individuals and populations, draw and develop talent, create new knowledge and expand our impact with funding from our generous donors.

Mental health and substance use disorders touch all of our lives and deserve to be treated with the same urgency, respect and seriousness of purpose as any other painful and potentially life-threatening health concern. We invite you to join us in this important work.

William C. Torrey, MD, D’80, HS’85-89 Raymond Sobel Professor of Psychiatry, Interim Chair, Department of Psychiatry Geisel School of Medicine at Dartmouth and Dartmouth Health

STATE OF NEW HAMPSHIRE CONTRACTS

65 with an annual funding level of

go.d-h.org/psychiatry

funded full-time equivalent positions

$18,577,497

INTEGRATING PRIMARY, MENTAL HEALTH CARE

PHOTO BY: MARK WASHBURN

COLLABORATIVE CARE MODEL MEETS PATIENTS WHERE THEY ARE TO PROVIDE HIGH-QUALITY PSYCHIATRIC SERVICES

Charles Bracket, MD, MPH, (left) and Matt Duncan, MD, MED’01 share a complex care decision.

At a time when the need for mental health services is greater than ever, behavioral health clinicians and psychiatrists at Dartmouth Health are meeting those needs where they often present: in a primary care physician’s office.

“Primary care has not historically been designed to deliver mental health care, yet these physicians now deliver more than 50 percent of the mental health care patients receive in the U.S.,” says Matthew Duncan, MD, MED’01, a psychiatrist at Dartmouth Health and an assistant professor of psychiatry at the Geisel School of Medicine. “We asked, ‘How can we amplify care and meet the need where it sits?’”

The answer to that question is a Collaborative Care Program at Dartmouth Health to support primary care practices and meet patients where they’re presenting.

The program began a decade ago with just one team at one clinic. Today, the program serves 17 clinics around the

region. The program addresses common disorders such as depression, anxiety, unhealthy alcohol use and other substance use disorders, including opiate use disorder.

Each team consists of a primary care provider (PCP), a behavioral health clinician (BHC) and a consulting psychiatrist, who are integrated into primary care offices. Instead of waiting for patients to recognize their own mental health needs, this model of care takes a proactive approach, screening patients to identify problems and providing treatment right away. In traditional medicine models, mental health care can be delayed several months or longer.

Dartmouth Health | Geisel School of Medicine Department of Psychiatry at Dartmouth Hitchcock Medical Center

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$1 MILLION GIFT ENDOWS AUTISM PROGRAM PHOTO BY: MARK WASHBURN

DONATION WILL SUPPORT SERVICES FOR PEOPLE WITH AUTISM AND DEVELOPMENTAL DISABILITIES

Kathleen Barros, PhD (from left); Omar Shah, MD, HS’21-22; Rebecca John, DO, HS’22-23; Jennifer McLaren, MD, HS’05-10; and Jonathan Lichtenstein, PsyD, MBA, discuss how neuropsychology testing can help tailor care to meet the individual’s needs.

Dartmouth Health has long been a leader in providing specialized healthcare clinics and community support for people with autism spectrum disorder and developmental disabilities. A generous gift from Jeff and Terry Marshall and the Thomas Marshall Foundation will support these initiatives for years to come.

Jennifer McLaren, MD, HS’05-10, associate professor at the Geisel School of Medicine and director of Behavioral and Neurodevelopment Services.. “It has also had a positive impact on many learners from different disciplines who will go on to provide highquality, comprehensive care to this patient population.”

The foundation recently committed $1 million to establish the Mosenthal Pediatric Autism Endowment, which will fund research activities, clinical care, administrative activities, patient and family support, and education for medical professionals and the community. The autism clinics are dedicated to supporting families, diagnosing and treating children with autism, and helping them live fulfilling lives.

The foundation’s gift will support several areas of service for patients and families. One such area is Behavioral and Neurodevelopmental Services (BANDS), which provides a central point of access for all referrals. This virtual center helps determine which of the Dartmouth Hitchcock Clinics would best serve the patient, preventing families from dealing with the stress of finding the right services and reducing the potential number of visits. BANDS includes a multidisciplinary group of providers from Child Psychiatry, Developmental Pediatrics, Pediatric Psychology, Pediatric Neuropsychology and Care

“I feel grateful for this gift because it has made a difference in the work we do at Dartmouth Health for patients and families, and it will allow us to continue to grow and make a difference into the future,” says 4

go.d-h.org/psychiatry

Supported Employment: Individual Placement and Support program for I feel grateful for this gift because it individuals with autism has made a difference in the work spectrum disorder The foundation’s gift and developmental also supports two multiwe do at Dartmouth Health for disabilities, which helps disciplinary clinics that patients and families, and it will secure competitive, provide comprehensive meaningful jobs for its assessments and treatallow us to continue to grow and participants. McLaren ment. One is the Autism make a difference into the future.” says that people with Spectrum Disorders/ high-functioning autism ADOS Clinic, which uses Jennifer McLaren, MD, HS’05-10 or developmental the Autism Diagnostic disabilities can Observation Schedule experience greater self-esteem and increase their (ADOS) to observe behavioral signs and symptoms of independence and social connectedness through their autism spectrum disorder. ADOS is a comprehensive bework, which also helps decrease stress for parents. havioral observation that has become the gold standard for helping to diagnose someone with autism. The other “When someone enrolls in the program, we identify the clinic is the Neurodevelopmental Psychiatry Clinic (NDPC), person’s interests and strengths and then help find a where children are evaluated and diagnosed by a team competitive job that fits those interests,” says McLaren, of providers from Child Psychiatry and Neuropsychology. who notes that employment matches have been identified in a variety of fields, such as at bakeries, retirement In addition to supporting children and families, these communities, retail businesses, technology companies clinics and other educational initiatives, such as regional, and more. These jobs pay at least minimum wage and are national and international presentations aimed at not designated specifically for someone with a disability. professionals, help train more healthcare professionals to competently and confidently serve patients with McLaren says that because mental health care is so autism and developmental disabilities. Currently, there poorly reimbursed by insurance companies, it is aren’t enough mental health care providers in the only through grants and philanthropic funding that overall mental health workforce, and the number of Dartmouth Health can continue providing these professionals in this subspecialty is even more limited. services and expand the program.

“Many providers don’t feel like they have the training or Jeff Marshall, a trustee of the Thomas Marshall expertise to care for this patient population, or they have Foundation, and his wife, Terry, recognized this need a significant gap in their knowledge base regarding best and the life-changing services McLaren and Dartmouth practices for these patients. We are determined to narrow Health are providing for people with autism. this knowledge gap though supervision of trainees and other learners, advocacy, lectures, continuing “The fund is named after one of my best friends, who medical education initiatives and publications,” says has a son with autism,” says Marshall, adding that his McLaren, who adds that increasing the number of skilled friend’s father, William Mosenthal, MD, was a forwardproviders will help create more equitable access to care thinking surgeon at Dartmouth Hitchcock Medical for individuals with autism spectrum disorder.

Center for more than 30 years. “Back then, pediatricians didn’t know how to diagnose autism. Today, the work at Equitable access also extends to the patient’s community Dartmouth Health and the work Jen has accomplished involvement and employment. Dartmouth Health is remarkable. I’m happy to help in any way I can.” recently hired a new employment specialist for the Management, and it also includes an employment specialist.

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To make a gift in support of these patients and their families, contact Matthew Hall at Matthew.R.Hall@hitchcock.org for gifts to the Department of Psychiatry and Polly Antol at Polly.Antol@hitchcock.org for gifts to the Dartmouth Health Children’s.

Dartmouth Health | Geisel School of Medicine Department of Psychiatry at Dartmouth Hitchcock Medical Center

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PHOTO BY MAGDA: CRISTINA CEPEDA GIL

Participating primary care providers and researchers in the DIADA: Detection and Integrated Care for Depression and Alcohol Use in Primary Care project helped create a system of digital therapeutics that has changed the way Colombian doctors serve their patients.

DIGITAL CARE BOOSTS WORKFORCE REACH PROJECT IN COLOMBIA SHOWS SUCCESS IN SUPPORTING DOCTORS AND PATIENTS THROUGH TECHNOLOGY-BASED CARE MODEL Countries around the world are feeling the strain on the mental healthcare workforce, with more people in need and fewer resources to help them. Lisa Marsch, PhD, a professor of psychiatry, and her colleagues at Dartmouth’s Geisel School of Medicine and partners in Colombia have been working on a science-based digital solution, which has had great success in Latin America.

Marsch partnered with Carlos Gómez-Restrepo, MD, PhD, the dean of the Faculty of Medicine, and other researchers at Pontificia Universidad Javeriana, Bogotá, on the project, called Scaling Up Science-Based Mental Health Interventions in Latin America. Also known as the DIADA project, which stands for Detection and Integrated Care for Depression and Alcohol Use in Primary Care, Marsch’s research was conducted in six primary care systems in Colombia and has two main parts. The first is training primary care providers on how to recognize potential mental health problems that have not routinely been discussed in a primary care setting.

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At a kiosk before an appointment, patients take a clinically validated screening for signs of depression or unhealthy alcohol use. The PCP receives an automated notification about potential problems and can discuss them with the patient at the visit. This speeds the process of addressing mental health issues, and a digital decision support tool helps doctors who may not otherwise diagnose the problem, particularly when it comes to alcohol use.

“Alcohol use is a big part of holidays and celebrations in some cultures, so many doctors understand it as a normal part of the culture, not as problematic,” says Marsch, whose research earned one of the most prestigious awards in medicine from Colombia’s National Academy of Medicine. “By flagging unhealthy levels of alcohol consumption, this technology is helping providers understand that there’s a medical risk from high-level use.”

The second part of the project is implementing a digital therapeutic, which has proven to be a successful

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Having science-supported care offered through technology is an extension of what our department is trying to do locally and regionally, and this is a global reach.”

William Torrey, MD, D’80, HS’85-89

treatment tool for patients. Marsch and her collaborators have created software that provides medical-grade therapeutic interventions via a mobile, digital form.

Having culturally relevant mental health treatment delivered digitally offers much-needed support at a time when there are too few mental health specialists, most of whom restricted to urban areas.

“It’s like having a clinician in your pocket—digital therapeutics extends the reach and impact of the workforce,” Marsch says. “This software can help you manage a mental health condition, and science has shown it can have a big impact on health.”

Before implementing the technology, clinics in Colombia were screening and diagnosing 0% of patients. Using the technology, however, clinics discovered 10% of patients met the criteria for depression and 2% for unhealthy alcohol use. Marsch and her colleagues followed patients for a year to assess their mental health status as they used the digital therapeutics, and they found most patients showed marked improvement with this model of care, even when their condition was considered serious or severe.

As the five-year project wraps up, Marsch is encouraged that healthcare systems in Colombia want to continue using this model as part of primary care. She also sees implications for improved mental health care in rural areas of the United States, where people also have limited access to the care they need.

INTEGRATING CARE The collaborative care model also promotes the normalization of mental health care. When the screening at a PCP’s office identifies a patient in need of mental health services, the doctor explains that there is a team at the practice who can help. Then the behavioral health specialist can come in to talk with the patient in an extended visit as well as provide telehealth outreach between primary care visits.

“The BHC can assess what’s going on with the patient, teach stress management skills and work with the PCP and psychiatrist to optimize medications,” Duncan says. “Most people tend to get better with these early interventions when, in a referral-based model, they would still be waiting for care.”

After initial visits, the team checks in with patients regularly to assess their mental health, gather patients’ reports of their symptoms using validated scales, and adjust patients’ care until their symptoms resolve, stepping up care if needed. In many cases, patients can receive several months of active care without having to go back to the doctor’s office.

This is a huge benefit, especially for patients who need mental health care but have difficulty accessing it.

Because the specialists are already at the PCP’s office, patients don’t have to make multiple appointments, take extra time off from work and find childcare in order to access appropriate care.

The Collaborative Care Model also benefits primary care physicians by giving them confidence that they can serve their patients’ needs right in their office. Consulting psychiatrists support the PCP to provide evidence-based psychiatric care.

William Torrey, MD, D’80, HS’85-89, interim chair of the Department of Psychiatry and co-investigator for the DIADA project, is thrilled with the results of the project and excited for the future.

While literature strongly supports the Collaborative Care Model and it is becoming the national standard, it is difficult and slow to implement, and reimbursement models have been slow to develop. Duncan credits the program’s success to the leadership at Dartmouth Health, especially that of William Torrey, MD, D’80, HS’85-89, the interim chair of the department, for his foresight in choosing this particular model of integrated care.

“Having science-supported care offered through technology is an extension of what our department is trying to do locally and regionally,” he says, “and this is a global reach.”

“D-H has invested a decade’s worth of time and money into the program,” Duncan says, “because it’s the right thing to do.”

Dartmouth Health | Geisel School of Medicine Department of Psychiatry at Dartmouth Hitchcock Medical Center

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CLOSING THE GAP Those experiences include feeling welcome as part of the healthcare team where their contributions are valued. Students consistently give high ratings on their course evaluations, noting in particular that they enjoy interacting with people with the lived experience of mental illness.

“Students aren’t standing by just watching what’s happening,” Frew says. “They are actively participating in providing patient care. The way you learn to be a doctor is by practicing, so being able to get involved is powerful for them and their education.”

Students have five options for doing their clerkship, including at the New Hampshire Hospital, where some of the most severely ill patients are treated. Providing high-quality care for these patients can be extremely rewarding, enough to inspire students to go into the specialty. Angie Lee, MD, MED’22, for example, had not planned to become a psychiatrist, but her clerkship experience changed her mind.

“The team at New Hampshire Hospital was so admirable, and I felt inspired by the quality of teaching and also the way they approached patient care,” Lee says.

“It was very much patient-centered care, considering people in the context of their environment and looking at the ecosystem of the individual.”

As she looks toward the future, Lee hopes to serve some of the most vulnerable child and adolescent patients, particularly queer youth,

and to provide gender- and sexual orientation-affirming mental healthcare.

In addition to preparing students for clinical settings, Dartmouth Health also offers research opportunities for residents who want to pursue academics. The residency has a dedicated spot for a gifted scholar to work with faculty researchers to support and promote their own research career.

Similarly, medical school graduates from any institution can apply for the Child and Adolescent Psychiatry residency track, a slot that guarantees them admission to the child psychiatry fellowship program at Dartmouth Health after their residency. Frew says this track has been helpful as a recruitment tool and also enables these residents to get earlier exposure to child psychiatry.

This year, 13 of the 90 Geisel graduates are entering psychiatry residencies, more than double the number of a typical year. On March 18, Match Day, 11 students matched into general psychiatry programs and two students matched into triple board programs, which are combined pediatrics/psychiatry/child psychiatry programs. The Dartmouth Hitchcock Medical Center Psychiatry Residency Program matched nine new PGY1 residents from across the country, including one Geisel student.

“The pandemic has raised awareness of the importance of mental health care,” Frew says. “We had a big year, and it’s exciting to add to the mental healthcare workforce.”

PSYCHIATRY

BY THE NUMBERS Dartmouth Health’s Department of Psychiatry at Dartmouth Hitchcock Medical Center and Geisel School of Medicine has an extensive clinical, educational and research presence.

FACULTY DISCIPLINES

MD

PhD

MA

NP

MD Psychiatrists PhD Psychologists and other doctoral-trained clinicians and researchers MA Master’s-prepared licensed clinicians NP Psychiatric advanced nurse practitioners

$37,789,787 Total Active Research Funding

43

Principal Investigators

10

Distinct Training Programs

Department of Psychiatry

One Medical Center Drive, Lebanon, NH 03766 dartmouth-hitchcock.org

Designer: Linnea Spelman

Writer: Ashley Festa