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Wisconsin Psychiatrist LeFlore Communications LLC



                                                The                                                                            2007
                                                                                                                               Vol.46 No.2


One Size Fits One: Approaches to School Violence
By Chris Morano, PhD
                       Over the past sev-       down over 40 percent since the early 1990s        awful episode in Pennsylvania occurred at
                       eral weeks, much has     (US Dept. of Education, 2005). Lest one           the hands of an adult who appeared to have
                       been written and said    think that our state or our municipalities are    no direct relationship to the school, but a
                       about school violence.   insulated in aggression, and have not expe-       history of violence toward young girls. The
                       As the director of a     rienced this precipitous drop like the rest of    commonality between all instances might
                       mobile crisis team for   the country, statistics from the Milwaukee        be that they occurred in a setting with a vul-
                       youth and families in    County Children’s Court show that teen            nerable population, and may spring from a
                       Milwaukee, I have        violence in general dropped about 25 per-         sense of powerlessness on the part of the
                       talked with numerous     cent from 2001 to 2005. Bullying, however         perpetrator.
                       children and teens       remains a problem, and occurs at an alarm-
                                                                                                  There have been many forums and media
who say their greatest fear is walking from     ing frequency, most often right under the
                                                                                                  excursions into what to do about such
home to the bus stop, to school, or back.       eye of supervising adults (Bully Project,
                                                                                                  violence. Most have emphasized some key
Urban violence is a raw reality, but now        2004). As an aside, youth suicide has also
                                                                                                  component related to a particular event. I
there seems to be renewed interest in safety    decreased by about 25 percent in the past
                                                                                                  submit that an approach to school violence
at schools, and if you subscribe to the views   decade or so (CDC, 2005). The CDC sug-
                                                                                                  has better odds at success if it contains ele-
espoused in public forums like the media,       gested several factors they believe contrib-
                                                                                                  ments of 1) preventative/proactive strate-
you will no doubt be concerned about the        ute to lower rates of youth suicide these
                                                                                                  gies, and 2) reactive/crisis response. Kids
burgeoning pattern of serious violence in       days, including better access to community
                                                                                                  need to feel safe at school, and a combina-
schools. You may also have witnessed the        mental health options, more acceptance of
                                                                                                  tion of subtle as well as obvious measures
march of experts who have detailed their        alternative lifestyles and less access to fire-
                                                                                                  may be the path to enhancing their sense
plan to address this issue. Anxiety disor-      arms. A sound solution-focused approach
                                                                                                  of security.
ders are now the number 1 diagnosis for         should lead us to consider what factors
youth, according to numerous sources, and       contributed to the drop in youth violence,        Of course, there are many steps schools
kids’ apprehensions about school fuel this      and how we can enhance those factors to do        and communities can take that involve
phenomenon. The purpose of this article is      even better. I posit several below.               structured, visible safety and prevention
two-fold: 1) to dispel the myth that youth                                                        planning. Schools can enlist undercover
                                                Second, the troubling phenomenon of
and school violence is increasing, and 2)                                                         law enforcement personnel, employ metal
                                                school violence is not a uniform one.
to discuss a multi-pronged approach to a                                                          detectors and lock doors if needed. One
                                                Each of the tragic incidents of the past
complex problem.                                                                                  report estimated that over half of US schools
                                                few months has its own terrible set of
                                                                                                  lock doors now during operation hours.
First, we must examine available data on        predicates, each suggestive of multi-lay-
                                                                                                  While these strategies can increase safety,
the problem. Many sources have identified       ered responses or solutions to prevent fur-
                                                                                                  they can also have the unintended effect of
that, much like youth suicide, youth vio-       ther episodes. These multiple-determined
                                                                                                  actually increasing students’ apprehension.
lence toward others has actually decreased      events warrant multi-pronged reactions by
                                                                                                  One school system in Texas took it to the
over the past decade or so. Nationally, the     the community. Some involve disgruntled
                                                                                                  next level, and has begun training students
US Department of Education, working with        students with authority issues. Others ema-
                                                                                                  to disrupt and fight back against aggressors
the Justice Department, has indicated that      nate from youth who have experienced
the rate of serious school violence has gone    years of intimidation and rejection. One                                     continued on page 4
The Wisconsin Psychiatrist

    The Wisconsin Psychiatrist is pub-
    lished four times a year — Spring,
                                                          Saying Goodbye to CHS Advocate &
    Summer, Fall and Winter — for mem-
    bers of the Wisconsin Psychiatric                     Friend, Ed Levin, September 28, 2006
    Association and those interested in
    its activities. Opinions expressed are                Reprinted from the University Wisconsin        Human Relations Social Development
    the author’s and do not necessarily                   Milwaukee, College of Health Sciences          Commission, as chair of the Milwaukee
    reflect the policies of the WPA. Articles             Web site.                                      County Human Rights Commission,
    submitted must be signed and are
    subject to review by the Editors and/or                                                              and as state counsel for the Wisconsin
    Editorial Board.                                      By Randall S. Lambrecht, PhD                   Psychiatric Association. Working closely
                                                          Dean and Professor                             with Milwaukee’s Fr. Groppi, Mr. Levin
    Articles may be reprinted. However,
    attribution    to   The  Wisconsin                    College of Health Sciences                     was a diligent campaigner of local civil
    Psychiatrist and two copies of the                    The University of Wisconsin-Milwaukee          rights efforts.
    reprint are appreciated.                              A poem written by his daughter, Lisa,
                                                          hung framed in his office at College of        Mr. Levin passed away in the presence
    Editorial Board                                                                                      of his beloved family on September
       Linda DiRaimondo, MD                               Health Sciences (CHS), the calligraphy
       Harold Harsch, MD                                  was in her hand. It read: “A man is only       24th. Services were held (the week of
       Edward Krall, MD                                   complete when he has a true friend to          September 25) at Temple Menorah. Mr.
       Jeff Marcus, MD                                    understand him, to share all his passions      Levin’s grandson, Sam, sang the tradi-
                                                          and sorrows with, and to stand by him          tional El Mal’ei Rachamim prayer in
    Contributing Authors                                                                                 Hebrew, while his granddaughter, Sophie,
       Michael Bell, MD
                                                          throughout his life.” Ed Levin was such
       Michael Blumenfeld                                 a friend.                                      translated in English. As a last act of
       Kenneth Casimir, MD                                                                               promotion for the College, his family cre-
       Harold Harsch, MD                                  Mr. Levin was a tireless promoter of           ated the “Ed Levin Memorial” benefiting
       Edward Krall, MD                                   College of Health Sciences. In his five-       College of Health Sciences. He is remem-
       Fannie LaFlore, MS, LPC, CADC-D                    year tenure as Special Assistant to the
       Randall S. Lambrecht, PhD
                                                                                                         bered as a consummate teacher, a staunch
       Nancy Shook, RN, LCSW, APNP
                                                          Dean, he drew on his extensive network         supporter of the underrepresented, and as
       Laurens D. Young, MD                               of colleagues and applied his savvy busi-      a dear friend.
       Steven Zelenski, DO, PhD                           ness skills to forge new partnerships and
                                                          to bring greater visibility to the College     Thank you once again, Ed.
    Administrative/Editorial Office                       and to the University. Prior to his work at
       Wisconsin Psychiatric Association                  CHS, he held a similar post for the School
       c/o Kathy Mohelnitzky
                                                          of Education, giving nearly 20 years of
       330 E. Lakeside St.
       PO Box 1109                                        dedicated service to UW-Milwaukee.
       Madison, WI 53701
       800.762.8967                                       For more than three decades, Mr. Levin
       Fax 608.283.5424                                   was an attorney in private practice special-
       E-mail:                             izing in corporate real estate law. During
                                                          this time, he taught law at UW-Madison
    The Wisconsin Psychiatrist accepts
    advertisements at the following rates:                and was a member of the Governor’s
    ADVERTISING RATES                                     Health Policy Council. He served as            Ed Levin with his grandchildren, Sam
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                                                          2005–2007 WPA Officers
    1/8 Page     $ 60      $ 50         $ 40     $ 30     President                        Assembly Representatives    Milwaukee Chapter President
    All advertising copy must be submit-                  Edward Krall, MD                 Clarence Chou, MD           Jon Berlin, MD
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    of the Editors and Editorial Board.                                                    Richard P. Barthel, MD
                                                          Past President                                               Southern Chapter President
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                                                          Molli Rolli, MD                                              Linda Di Raimondo, MD
    lines and principles of the American                                                   Jon E. Gudeman, MD
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                                                          Harold Harsch, MD

                                                                                                               WINTER 2006 - 2007

President’s Comments
By Edward Krall, MD

                       The Wisconsin Psy-       in fewer providers being willing to           cessful.
                       chiatric Association     see Medicaid recipients, which in turn      • How can we leverage our overextended
                       was approached by        results in poor access and poor care.         capacity to manage and triage patients
                       an official in the     • Nurse practitioners and primary care          with clear protocols for primary care to
                       Doyle administra-        providers end up providing care by            utilize?
                       tion and asked to        default, which they may not be com-         • What about using telepsychiatry to link
                       consider advocat-        fortable with or competent to do.             resources from areas of surplus to those
                       ing for a change in                                                    with scarcity?
                       the Medicaid reim-     The DHFS Position                             • He is open to a multi-year study with
                       bursement system       Mr. Hayden had been in his post for             us to look at opportunities like psychi-
                       for mental health.     3 months and 3 days, having recently            atric involvement with the Health Care
It was their impression that while insid-     replaced Mark Moody. He previously was          Advantage in Dane County or grant
ers in the administration want to advocate    the president of Dean Health Care and           proposals for providing care to children
for change, they can’t do as much as they     has also served as the administrator of a       and adolescents in rural areas similar to
would like because we are silent on this      mental health group and is aware of reim-       what has been done in dentistry.
issue. Other groups such as the dentists      bursement concerns for mental health.         • There has been no medical director at
are very active and already lobbying hard     He acknowledged that there is an access         the state level for mental health and
to ask for changes with the new budget        problem and admitted that there has been        substance abuse issues. They are devel-
cycle.                                        no rate increase for a number of years. He      oping a proposal for this position.
So we agreed. On November 6, 2006,            alluded to incentive options with incre-
                                                                                            DHFS Concerns
a group made up of Mike Blumenfeld,           mental adjustments in areas of need but
                                                                                            Mr. Hayden and Ms. Santala outlined
Karen Carney, our acting Executive            he stated emphatically that, in his opinion
                                                                                            some of the areas of need on the DHFS
Director, Molli Rolli, Jerry Halverson,       “The answer is not just to throw money at
                                                                                            radar screen.
Rachel Molander, resident, and I met          the problems.” There are multiple groups
with Kevin R. Hayden, Administrator,          looking for increases. The short answer       • Rural mental health. There is a critical
Division of Health Care Financing, and        was that there would be no increases.           shortage of services in rural areas; 62
Sinikka Santala, Administrator, Division      However, he posed this question, “How           of 72 counties have shortages of men-
of Disability and Elder Services, at the      can WPA and DHFS partner to improve             tal health providers. The county-based
Department of Health and Family Services      care of their recipients and our patients?”     system clearly is inadequate
(DHFS).                                                                                     • Atypical antipsychotics—The cost of
                                              He suggested engaging in a dialogue on
                                                                                              and management of these medications
Our Issues                                    constructive programs to get at the issues
                                                                                              are an ongoing concern. They value our
Our approach was to advocate for our          and together to develop parameters for
                                                                                              input on this and emphasize the need to
members and our patients. We wanted           getting at solutions. He is interested in
                                                                                              continue to be active.
this to be a friendly, open discussion to     new “concept designs.”
                                                                                            • At a county level, there is a need for
educate and find out DHFS’s position and                                                      better crisis intervention services for
                                              He challenged us. At the WPA level, what
how we as an organization could work                                                          hospital alternatives.
                                              can we do to help advocate for and sell
with them.                                                                                  • DHFS is developing a Comprehensive
                                              Medicaid to our members? Are we willing
We represented different practices from       to ‘evangelize’ with our members? He is         Community Services program (CCS)
urban to rural, academic to private, indi-    very big on teaching and educational part-      that is intended to be an intermediate
vidual to group. Our discussion points        nerships. Here are some of his thoughts.        between Community Support Program
were as follows:                                                                              (CSP) and outpatient treatment. This is
                                              • Work with DFHS to develop strategic           a new benefit that will offer a kind of
• There has been no change in the               educational programs for rural primary        case management.
  Medicaid fee schedule for psychiatry          care providers to partner with psychia-     • Long-term care in the next 5 years will
  since 2002.                                   try and extend care to those in need.         get a comprehensive overhaul. DHFS
• MA is not covering costs of providers         Dean did this with its primary care
  and inadequate reimbursements result          providers and apparently was quite suc-
                                                                                                                     continued on page 4

The Wisconsin Psychiatrist

President’s Message                           School Violence                                   alarm. Sometimes, as professionals, we are
continued from page 3                         continued from page 1                             called on to lend meaning and support in
                                                                                                times of high challenge. This is a daunting
  recognizes that elderly with substance      with guns. This idea, along with arming           task, but in the case of school violence, we
  abuse and mental health issues do not       teachers, is dubious. It is hard enough for       know a few things that should serve as a
  get adequate treatment. Of individuals      teachers to inculcate the day’s lesson, and       guide:
  with developmental disorders, 40 per-       get students to attend to it, let alone protect
                                                                                                • The CDC and other sources note that vio-
  cent have mental health issues that need    against potential guerrilla tactics. Even
                                                                                                  lence, self- and other-directed in youth,
  to be addressed.                            SWAT teams are sometimes confounded in
                                                                                                  has decreased over the past decade
• In Milwaukee, SED (severely emotion-        such situations.
                                                                                                  or so.
  ally disturbed) kids will get good wrap-
                                              Other measures could involve more deliber-        • Community-based and individually tai-
  around care but other kids, like those in
                                              ate and proactive components that address           lored approaches have shown sound
  the juvenile justice system, do not get
                                              some of the roots of student aggression. To         promise in helping youth with serious
  the care they need.
                                              begin, schools should focus on developing           emotional disturbance, and have likely
Next Steps                                    meaningful relationships and connections            contributed to the decline in overall
Ms. Santala observed that this was the        with families and communities. Students             youth violence.
first time that our Association, and in       who demonstrate early warning signs of
fact, the first time our profession, has      trouble (isolation, rejection, victimizing        When tragedy strikes, one of the most pro-
been represented at the DHFS table. She       behaviors, intolerance of differences)            foundly comforting experiences a child can
emphasized that we need to be visible and     could be identified and helped with early         have is the calm and certitude of the adults
active participants if we are to be heard.    intervention strategies targeting bullying        around them who matter the most. Every
This is a good start.                         dynamics. Students could be encouraged to         effort should be made to help, teach and
                                              form leadership groups (call them “Young          support schools, communities and fami-
They would welcome us back more fre-          Heroes”), to mentor and support peers, and        lies early in the sequence, before tragedy
quently and are willing to brainstorm with    provide a link to school administration.          strikes. Keep recent events in perspective,
us about ‘designing a reconfigured model      Administrators could more fully support           work with schools and communities using
of care.’ We are planning to go back in       mental health, school social work, guid-          a multifaceted plan, and create a positive
March.                                        ance and other staff to more deeply impact        expectation of the future for youth. The
                                              students who show early warning signs,            bottom line is that kids who feel safer, learn
Mr. Haden will talk with Helene Nelson,
                                              and dialogue proactively with kids about          better.
the Secretary for Health and Human
                                              fear, violence and safety concerns. Further,
Services, in the next week regarding                                                            Chris Morano, PhD—Dr. Morano is the Clinical
                                              schools could more directly facilitate con-       Program Director for the Mobile Urgent Treatment
financial indicators for our request of a
                                              nections between staff and students, by           Team (MUTT) of Wraparound and Milwaukee
rate increase.
                                              offering training in basic communication,         County, a service of Milwaukee County aimed at
We are also planning to meet with Jim         to improve trust. It’s very challenging to        responding to child and family crises in the com-
                                                                                                munity. Raised in upstate New York, Dr. Morano
Johnston, administrator for the Governor’s    have a difficult, but crucial, conversation       completed master’s and doctoral programs at the
staff, in the Department of Administration    with a youth unless you have some “rela-          University of Wisconsin-Milwaukee. Dr. Morano is
(DOA) hopefully before Thanksgiving as        tionship capital” in the bank. The time to        a licensed psychologist and has worked in various
they are developing a budget for the next     talk with youth is now, six months prior          capacities in the mental health field over the last
                                                                                                15 years. Currently with Milwaukee County, he has
year, again with the intent of educating      to a problem, not when the problem is
                                                                                                been employed at both private and public psychiat-
and advocating.                               erupting. Finally, schools should create,         ric facilities, and is a consultant for the Children’s
                                              and practice, a safety plan. Everyone loses       Court of Milwaukee, as well as with the Wisconsin
Mike Blumenfeld, our legislative lobby-       some of their planning and reactive capac-        State Disability Bureau. Dr. Morano was recently
ist, commented that this was a very posi-     ity in a crisis, and rehearsal is one of the      appointed to the National Association of Counties
tive meeting. We have their ears. We have     best antidotes.
                                                                                                Board for Early Childhood Development. In addi-
an excellent opportunity to partner. This                                                       tion to community mental health for children, he
                                                                                                is also very interested in forensic psychology, and
gives us the chance to be innovative with     In short, our children are our most precious
                                                                                                consults frequently with the courts on issues of
areas of identified need and better serve     assets, and we entrust them to schools            competency to stand trial, waiver and NGRI. Dr.
our patients. The WPA needs its members       every day. Serious school violence and            Morano has published research on adolescent
now more then ever to step forward and        rampage killings have captured the national       suicidal behavior, and authored articles on com-
work with the Council in this endeavor.       attention of late. There has been increasing      munity mental health issues for high-risk children.
                                                                                                Finally, he has presented locally and nationally on
                                              alarm about the safety of today’s school,         the mental health and behavioral needs of high-
                                              and to some extent it is an unfounded             risk youth.

                                                                                                                  WINTER 2006 - 2007

The Other Dual Diagnosis: Part 2
By Nancy Shook, RN, LCSW, APNP

Part 1 of this article, published in the sum-   that promotes use by busy professionals.      support in modifying behaviors and can
mer 2005 issue of Wisconsin Psychiatrist        Creating opportunities for specialists pro-   help patients learn to generalize desired
discussed the problems and challenges           viding day-to-day support to individuals      behaviors in different settings. Crisis sup-
associated with providing accurate diag-        with developmental disabilities and psy-      port teams and “safe houses” can help
nosis and care to individuals with the          chiatrists and other mental health practi-    avoid unnecessary institutionalization dur-
“other” dual diagnosis. Part 2 discusses        tioners to share perspectives, knowledge,     ing behavioral or environmental crises.
some of the benefits of providing this care,    and practice tips would “demystify” the
and makes some recommendations.                 two aspects of this dual diagnosis for both
                                                                                              What are the benefits of providing psy-
                                                                                              chiatric care to persons who are dually
The term “dual diagnosis” in psychiatric        Third: The settings that are available for    diagnosed with developmental disabili-
circles usually refers to an individual with    providing mental health care are some-        ties and mental illness?
both a primary mental illness and a sub-        times not well designed for persons with
                                                                                              There are many benefits to be gained
stance-related disorder. There is, however,     developmental disabilities. Larger rooms
                                                                                              from providing psychiatric care to persons
another dual diagnosis: that of mental          may be needed to accommodate pres-
                                                                                              dually diagnosed with developmental dis-
illness combined with a developmental           ence of support teams at appointments.
                                                                                              abilities and mental illness. Access to
disability.                                     Some individuals with developmental dis-
                                                                                              appropriate psychiatric care can make the
                                                abilities may need room to move about or
What recommendations can be made                                                              difference between successful community
                                                maintain additional personal space dur-
regarding the provision of comprehen-                                                         living versus a lifetime in an institution
                                                ing the appointment. Accessible entrances
sive and appropriate mental health                                                            or in a very restricted setting. Successful
                                                and facilities are necessary for people
care to persons dually diagnosed with                                                         treatment for mental illness can be the
                                                who require physical accessibility due
developmental disabilities and mental                                                         beginning of wonderful new life opportu-
                                                to brain injury, cerebral palsy or other
illness?                                                                                      nities. Observing the person’s symptoms
                                                mobility problems. Design of rooms and
                                                                                              decrease and watching him or her make
First: One significant challenge to obtain-     furnishings needs to be done with consid-
                                                                                              progress toward life goals can be very
ing psychiatric treatment for persons with      eration to safety for people with unusu-
                                                                                              professionally satisfying for providers and
developmental disabilities is the inad-         al behaviors. Reception personnel need
equate reimbursement under the current          methods to adapt their interactions to
Medical Assistance program. This dis-           meet the needs of people with a dual diag-    The presence of support teams in a person’s
incentive is especially acute when the          nosis. Waiting rooms and clinic rooms         life can help to improve compliance with
person’s needs require more than the            need to have entertainment activities that    medication regimens. It can also improve
average time allotment and may require          are cognitively, developmentally and age      reliability of attendance at appointments
environmental or personnel modifica-            appropriate. Information about diagnoses      and provide assistance in helping a person
tions. Increasing reimbursement and add-        and treatments needs to be provided in        learn new coping strategies. Collaborating
ing more flexible billing arrangements          forms accessible to persons who may not       with support providers can make the role
require advocacy for policy reforms.            read, or whose cognitive level is below       of the psychiatric provider much more
                                                the average.                                  satisfying and less stressful. Knowing
Second: Psychiatrists and other mental
                                                                                              how to best utilize all the members of the
health care providers need access to nec-       Fourth: Ability to provide effective psy-
                                                                                              support team can result in better care for
essary information about developmental          chiatric services to persons with devel-
                                                                                              the individual involved.
disabilities. They need to know about           opmental disabilities is greatly improved
community support systems for people            by a knowledge of how the developmen-         Community support providers can pro-
with developmental disabilities. Extensive      tal disability community support system       vide helpful assistance and suggestions.
educational material is available: internet     functions. One needs to know how medi-        They may be able to give important
resources, classes, seminars and interested     cations and treatments are delivered in       information about the person’s behavioral
specialists. This information is not always     the supported living community and what       history, previous reactions to medication,
well disseminated to the psychiatric com-       resources are available to provide assis-     or periods in the person’s life when they
munity. In some cases it is not available in    tance to the person, provider and team.       were more emotionally and behavior-
a format (time, dates, locations, or certifi-   The presence of community behavioral
cation for physician continuing education)      support specialists can provide adjunct                                continued on page 11

The Wisconsin Psychiatrist

Podcasting Part 2: Creating Your Own Podcast
By S. G. Zelenski, DO, PhD

                         Okay, now you          radio or TV. Pay attention to what makes       There are two schools of thought on
                         have listened to a     the presentation “fluid” and interesting.      recording your podcast: you can purchase
                         bunch of podcasts                                                     an all-in-one program that can record, edit,
                                                You are not just presenting information;
                         and are itching to                                                    and distribute your podcasts from a single
                                                a podcast should be entertaining so that
                         make one yourself.                                                    interface. Or you can save money by
                                                people will want to listen to it. What
                         “Why?” you say.                                                       using a general purpose audio recording
                                                annoys you when you listen to a speaker?
                         The reasons vary                                                      program—even free programs are avail-
                                                Maybe long, embarrassing pauses, ums,
                         from     “because”                                                    able. However, with this option, there will
                                                uhs, hesitation, repetition, rambling, an
                         to      “spreading                                                    be more steps involved in creating your
                                                uninteresting topic or just too long. Once
                         the word to fam-                                                      podcast, since the program isn’t designed
                                                you have decided on the theme for your
                         ily and friends” to                                                   specifically for podcasting.
                                                podcast, it is important to think about and
“expanding your ability to reach your
                                                understand your audience, then present         The all-in-one option
patients with specific information in your
                                                your content in a way they can relate to.      A favorite all-in-one podcasting solu-
own voice (remember transitional objects)
                                                Writing an outline will help you to avoid      tion is Propaganda (
and accurately.” So, how to do it? In this
                                                any awkward silences, and also help you        Propaganda/3000-2170_4-10509667.
article, I will talk about creating a podcast
                                                to formulate your ideas into a strong pre-     html). This well-designed program fea-
that someone might want to listen to, and
                                                sentation. Obviously, you don’t have to do     tures multitrack recording, sound effects
in the final article I will show you how
                                                any of this; you can just jump in and try      and transitions, a very functional arrange-
to publish one. This piece is based on a
                                                some ideas and see how they come out.          ment window, and plenty of tools for
course in Podcasting originally published
                                                                                               exporting your show. The simplified step-
by                                    Let’s take a look at hardware. The better      by-step process makes it easier to handle
                                                the quality of the microphone input and        the more technically advanced elements
In order to create your own podcast, I
                                                sound card and the quieter the recording       of podcasting, such as the creation of the
recommend that you have the following
                                                environment, the better the quality of the     XML files RSS requires ($49.95). On
hardware and software:
                                                recorded podcast. A few recommenda-            the Mac, Garage Band (
• A home computer (Mac or PC)                   tions include Senheiser’s PC 150 headset.      ilife/garageband/) is also very effective
                                                Price can be as low as $40 with shipping       with a simple, intuitive interface allowing
• A headset with a noise-canceling micro-
                                                from an internet store, or Logitech USB        you to mix tracks and sound effects and,
                                                Headset 250 with prices as low as $30.         for many Mac users, it is free. Purchase
• A portable MP3 voice recorder                 Compare specifications and shop for a          of the entire iLife suite including Garage
                                                good deal. Make sure that the headset is       Band is $79.
• Audio recording/podcasting software           comfortable and that it is compatible with
  (such as Audacity, Propaganda, or             your computer. If you record your podcast      Another option is Industrial Audio
  iPodcast Producer)                            on the road, use a good MP3 player that        Software’s aptly named ePodcast
                                                has an audio jack and use a good external      Producer (www.industrialaudiosoftware.
First, we’ll learn some tips on developing
                                                microphone. Make sure you record at a          com/products/ipodcastproducer.html).
a podcast, as well as discuss microphone
                                                sampling rate no lower than 32Kbps for         This program is a start-to-finish solution
basics. What will your podcast be about?
                                                MP3 and 44.1 KHz for WAV.                      that lets you record and edit podcasts,
It could be something personal like an
                                                                                               create RSS feeds, and upload the finished
interview with an elderly family member         PODCAST RECORDING                              product via a built-in FTP client—all in
that you want the rest of the family to         SOFTWARE
                                                                                               one interface. It’s priced at $249.95, but
hear, or maybe your standup comedy act,         One of the best things about podcasting is
                                                                                               the same company also produces a slight-
or something professional like a “live”         that it doesn’t cost you an arm and a leg to
                                                                                               ly less robust and more consumer-ori-
report of a conference you are attending        get in and test the waters. While it’s cer-
                                                                                               ented version called the ePodcast Creator,
or your comments about an interesting           tainly possible to spend thousands on high-
                                                                                               for $89.95.
grand rounds. But before you pick up the        end mics and recording software, the part-
microphone, you should do some plan-            time podcaster can easily create profes-
ning. Start by listening to professionals on    sional sounding recordings on the cheap.

                                                                                                                         continued next page

                                                                                                                  WINTER 2006 - 2007

Podcast continued from page 6
The general purpose software                    someone else’s studio and once you had        obtain_a_license.aspx , or other licensing
option                                          built up some confidence, then choose the     groups). The same restrictions apply to
Audacity (            best method for you.                          copyrighted films and television shows.
3000-2170_4-10514927.html) is a free,
open-source multi-track audio editor and        RECORD YOUR PODCAST                           TIP: Try to keep your show casual, con-
recorder that is widely used by podcast-        First, know your recording software and       versational and continuous. And remem-
ers. It includes a number of useful features    use the default settings the first time.      ber that if you make mistakes, you can
and plug-ins, and has an interface that is      Technical glitches can ruin an otherwise      always edit them out later, but planning,
intuitive and easy to use. It’s available for   perfect podcast, so start by making a few     an outline and practice before the actual
Windows, Mac and Linux.                         sample recordings to test the software,       recording can save a lot of frustration and
                                                adjust volume levels appropriately, and       time later. It’s usually easier to do it right
So what’s best for you?                         make sure everything works.                   first than try to fix it later.
If you are an experienced computer user
and enjoy having control over all seg-          Sample rates                                  Edit your Podcast
ments of making and publishing a pod-           Set the sample rates for your recording.      Now, you’ll learn how to edit your pod-
cast, and you don’t like to spend money,        If you’re just recording voice, anything      cast, and the proper way to save the file
then Audacity and other freeware prod-          higher than 44.1KHz and 16-bit sampling       for correct indexing on the Internet.
ucts are best for you.                          is overkill for most noncommercial pur-       Once you’ve recorded your show, you
                                                poses. If music factors heavily into your     might identify some parts that you’d
If you are less technical, have a few bucks     podcast, however, consider higher rates,
to spend and want to be guided through the                                                    like to remove, like long stretches of
                                                but keep in mind the resulting file will      silence, or mistakes that you’d like to
project by the software, then Propaganda        be larger.
or ePodcast Producer or Garage Band are                                                       clean up. Whether you are using Audacity,
for you.                                        Sound effects                                 Propaganda, GarageBand, or ePodcast
                                                Many people also like to incorporate          Producer, editing your sound file is an
Remember, be honest as you can get eas-         sound effects into their podcasts. If you     easy fix, and works the same way.
ily frustrated by the project and abandon       want to import sound effects or intro and
it if it becomes too much of a nuisance.                                                      1. To find stretches of silence, look for
                                                exit music with Audacity, you need to first
Ideally, you could do your first podcast in                                                   areas in the voice track where the wave-
                                                record your podcast, then locate the audio
                                                                                              form becomes an almost straight line.
                                                on your computer’s hard drive, and final-
                                                                                              2. Use your cursor to highlight the region
                                                ly bring the audio into the program by
                                                                                              you want to remove (much the same way
                                                clicking on the ‘import audio’ tab in the
       The Wisconsin                            project menu. With Propaganda or ePod-
                                                                                              you select text in a word processor).
                                                                                              3. Verify that this section is the one you
                                                cast Producer or Garage Band, you can
   Psychiatric Association                      add intro music, sound effects, and other
                                                                                              want removed by hitting play and listen-
                                                                                              ing to it.
                                                audio into your podcast in real time, as
                                                                                              4. Hit delete.
      2007 Annual                               well as other features that let you produce
                                                your podcast as if you were in a radio
                                                                                              5. Listen to that portion of the track to
                                                                                              make sure that the deletion hasn’t caused
      Conference                                studio. It goes without saying that if you
                                                include music in your podcast, you must
                                                                                              any clicks or other undesirable effects. If
                                                                                              you’re dissatisfied for any reason, undo
                                                respect copyright laws. Under US law,
         March 30 – 31                          podcasters may not use copyrighted music
                                                                                              the edit and try again. Prevent awkward
                                                                                              moments by deleting stretches of silence
                                                in their podcasts or videoblogs (except
                                                                                              in your podcast. You can use this same
                                                for music permitted under fair use [www.
        Osthoff Resort                ] and except
                                                                                              technique to get rid of “uhs and ahs”. After
                                                                                              you’ve cleaned up the file, the next step is
                                                for music licensed by ASCAP [www.
       Elkhart Lake, WI               ], BMI [www.bmi.
                                                                                              to combine your tracks into a final mix.
                                                                                              This combines everything you’ve record-
                                                                                              ed into a single stereo track. Generally
    MARK YOUR                                   sing&OVKEY=music%20licensing&OV
                                                                                              you will save the mix as an uncompressed
                                                                                              WAV or AIFF file (either one will work)

  CALENDAR NOW!                                 OVKEY=podcasting&OVMTC=standa
                                                rd], SESAC [                                     continued on page 8

The Wisconsin Psychiatrist

Podcast continued from page 7
that will give you a “master” file to work         IMPORTANT: In Audacity, when                      The first time you export a file as an MP3,
from and a backup in case you have a               exporting an MP3, this is your chance to          Audacity will ask you to locate your MP3
problem exporting to MP3.                          add ID3-tag information: your name, the           encoder. Point Audacity to wherever you
                                                   name of the podcast, and so on. Be sure           saved the file, and you’re ready to go.
NOTE: Before mixing to a single stereo
                                                   to enter this information because without
track, carefully review the balance of your                                                          TIP: Make your podcast jazzier and more
                                                   it, listeners won’t be able to find your
voice and any music or sound effects.                                                                professional by adding loops: snippets of
                                                   show on their MP3 players. Podcasting
This is your one chance to alter the rela-                                                           music used for everything from opening
                                                   software like Propaganda is a bit more
tive levels between your voice and any                                                               the show to introducing specific seg-
other audio tracks you’ve added. Once              intuitive, and allows you to save the file
                                                   with some additional information that will        ments. Find thousands of freely avail-
you have created a single stereo track, you                                                          able loops at Flash Kit. (www.flashkit.
won’t be able to make individual track             help you with your next step: publishing
                                                   your podcast. If you upload your file to          com/loops/) or or Cylinder
                                                   one of the free servers that I will describe      Preservation and Digitization Project (cyl-
Turn your final mix into an MP3                    in the next article, they will also ask for
The last step is to take your final mix and        this information.
convert it into an MP3 file—the standard                                                             Well, that’s it for now. If you have ques-
format of all podcasts. Open your final mix        BE PREPARED: Due to patent restric-               tions e-mail me at Ask.Zelenski@gmail.
in your recording software, and export the         tions, Audacity cannot automatically              com and if they might be of general
file as an MP3. To do this in Audacity, you        export MP3 files by itself. In order to           interest, I will publish them with my best
simply choose File -> export as MP3. Be            export your file as an MP3, you’ll have           answer in the next issue. If you don’t want
sure to export using a 32Kbps to 64Kbps            to download the “libmp3lamelibrary”               your name included, please tell me that
bit rate. You will be prompted to name the         (             as well. Next issue we will finish up with
file, and pick a location to save it on your       exportmp3.html) and choose a location for         how to publish your podcast.
computer.                                          it (preferably your Audacity directory).

    Wisconsin Medicaid Preferred Drug List—
    Atypical Antipsychotics
    By Harold Harsch, MD

    The Medicaid Pharmacy Prior Authorization (PA) Committee met on        response and the lack of evidence supporting superiority of one over
    March 29, 2006, to review the class of Atypical Antipsychotics for     another, to feelings that Zyprexa was unsuitable for long-term use
    the state’s Preferred Drug List (PDL). From that meeting, Clozaril,    and should be non-preferred. Secretary Nelson subsequently made
    Fazaclo, Risperdal, Geodon, Seroquel and Abilify were recommend-       the decision that Fazaclo, Symbyax, Zyprexa and Abilify would be
    ed to be preferred and Symbyax with Zyprexa as non-preferred. The      considered non-preferred drugs on the Medicaid PDL effective July
    PA committee passed this motion 6-0.                                   5, 2006.

    Earlier this year, the Secretary of the Wisconsin Department of        Wisconsin had spent about $7.5 million on Atypical Antipsychotics
    Health and Family Services, Helene Nelson, established a “Mental       in the first quarter of 2006. Abilify and Zyprexa had the highest “per
    Health Drug Advisory Group” to further review and comment on           patient cost” to Wisconsin of the atypical agents.
    recommendations from the PA committee concerning pharmaceutics
    prescribed for mental health issues. This group consists of seven      To minimize the impact of this decision on patients, the department
    psychiatrists from both community and academic settings in addition    also recommended the following:
    to mental health consumers and members of mental health advoca-        • Patients stabilized on a non-preferred agent will be allowed to
    cy groups. This committee had a lively discussion about the Atypical      continue this medication without PA.
    Antipsychotics and the PDL in April 2006. Sentiments ranged from       • If it is medically necessary to use a non-preferred agent that it be
    advocating open access to all atypicals because of individual             “simple and easy” to obtain PA.

                                                                                                               WINTER 2006 - 2007

Your WPA Lobbyist Election Update
Michael Blumenfeld, WPA Public Affairs Counselor

                      November               Democrats will control the Senate with         • The proposal maintains Community
                      10, 2006               a thin 51-49 majority. At the time of this       Aids at its base 2006 level. Community
                     November 7 was          writing, there are still several House races     Aids provides funding to counties to
                     a big day for           that are too close to call, but the Democrat     use for social, mental health, alcohol/
                     Democrats both          majority is expected to be 232-203 (or           drug abuse and disability services.
                     in      Wisconsin       close to that), which means the Democrats      • Two major initiatives from DHFS are
                     and nationwide.         picked up 30 seats.                              continuing statewide expansion of Fam-
                     Governor Doyle                                                           ily Care and expanding BadgerCare pur-
                                             State Budget Process Underway
                     won     re-election                                                      suant to the Governor’s BadgerCare Plus
                                             The process of developing the state’s 2007-
                     with nearly 53 per-                                                      proposal.
                                             2009 biennial budget formally began in
                     cent of the vote,
                                             mid-September when state agencies sub-
and control of the Senate will be in                                                        Some of the factors that will boost the
                                             mitted their requests and recommenda-
Democratic hands next session. Senator                                                      cost of maintaining the MA program
                                             tions to the Department of Administration
Judy Robson (D-Beloit) will be Senate                                                       include the following:
                                             (DOA). The DOA is working closely with
Majority Leader. Senator Dave Hansen                                                        • After falling by an estimated 0.7 percent
                                             the Governor’s office to consider the agen-
(D-Green Bay) will be Assistant Majority                                                       this year, MA caseloads are expected to
                                             cy requests and develop the Governor’s
Leader. Senator Fred Risser (D-Madison)                                                        grow by 4.3 percent in FY 08 and 3.2
                                             budget proposal. The Governor’s budget
will be Senate President. Republicans                                                          percent in FY 09, causing a two-year
                                             will be released in February and sent to
elected Senator Scott Fitzgerald (R-                                                           spending increase of about $93 million
                                             the Legislature as proposed legislation.
Juneau) to serve as Minority Leader and                                                        GPR.
                                             It will be referred to the Joint Committee
Senator Joe Leibham (R-Sheboygan) as                                                        • Changes in “service intensity” (i.e., the
                                             on Finance, which will hold public hear-
Assistant Minority Leader.                                                                     amount and types of services used) are
                                             ings and begin the process of amending
                                                                                               expected to increase GPR spending by
Democrats took control of the Senate by      and passing its own version of the budget
                                                                                               more than $91 million over two years.
picking up four seats. Gone are Senators     during the spring. Usually the budget
                                                                                            • Gradual reductions in the federal match-
Tom Reynolds, Dave Zien, Ron Brown,          is passed by the full legislature in late
                                                                                               ing rate will increase GPR spending by
and Cathy Stepp, who decided not to          June or early July and sent back to the
                                                                                               about $9.4 million.
seek re-election. Replacing them are Jim     Governor for his review and vetoes.
Sullivan, Pat Kreitlow, Kathleen Vinehout,
                                             Here are highlights from the Department        The entire DHFS budget request can be
and John Lehman, respectively.
                                             of Health and Family Services budget           found at:
In the Assembly, Democrats gained eight      request:                                       dhfs/OSF/Budget/DHFS07-09Budget.pdf
seats, which cut the Republican majority                                                    Senate Health Care Reform
                                             • DHFS is seeking a $343 million “cost
from 60-39 at the beginning of the 2005-                                                    Committee Update
                                               to continue” increase in state gener-
2006 session to 52-47 for the 2007-2008                                                     The Senate Select Committee on Health
                                               al purpose revenue (GPR) dollars for
session. Both parties plan to caucus next                                                   Care Reform, which was formed earlier
                                               Medical Assistance-related programs,
week to elect leadership.                                                                   this year, held the last in a series of six
                                               which break down as follows:
The one bright spot for Republicans in       • $305 million over two years to main-         public (but invited speakers only) hear-
Wisconsin was the election of J.B. Van         tain Medicaid ($90 million in FY 2008        ings on October 17. The committee has
Hollen as Attorney General. Van Hollen         and an additional $215 million the next      been hearing about high health care costs
defeated Dane County Executive Kathleen        year, relative to the FY 2007 base).         and various proposals to reform the sys-
Falk by just over 9000 votes out of over     • $16.6 million over two years for             tem, from comprehensive to incremen-
2 million cast.                                BadgerCare.                                  tal. Later this month, the committee will
                                             • $21.3 million for SeniorCare.                begin to consider legislative proposals
On the federal front, the big news nation-   • Total MA spending from all sources is        from members that it may introduce dur-
ally was both the House and Senate control     expected to reach $4.62 billion in FY        ing the 2007-2008 session.
switching to the Democrats; in Wisconsin       2007 and $4.88 billion in FY 2009.
it was Democrat Steve Kagen defeat-
ing John Gard in the 8th Congressional
District.                                                                                                           continued on page 14

The Wisconsin Psychiatrist

Editorial: The Formulary Mess—
Can psychiatrists still practice medicine?
By Harold Harsch, MD

                       Several psychia-       able as a generic, not because it was the        fill this prescription. He was in the hos-
                       trists have come       best SSRI for Medicaid and Seniorcare            pital for weeks, my estimate that it cost
                       to me and asked if     patients. However, why an insurance com-         $30,000 to stabilize this patient. He
                       the WPA could do       pany would ask for prior authorization for       was off of medications for days. I don’t
                       anything about the     generic medications or agents such as            know the outcome of this scenario for
                       increasing requests    Cytomel escapes normal logic.                    the patient.
                       for prior authoriza-
                                              I have found that the new Medicare Part          Case Three: A former nurse was admit-
                       tion for psychiat-
                                              D program created a nightmare of prior           ted for depression and suicidal ide-
                       ric medications. I
                                              authorization requests and denials. Let me       ation.
                       have recently seen
                                              share some frustrating cases.
                       this include a prior                                                    She had problems with recurrent
authorization request for Cytomel, used         Case One: A women in her middle 70s            depression and had been maintained
as an augmentation agent, and carnitine,        was stabilized and doing relatively well       on Serzone for almost a decade. I was
used in a patient with elevated ammonia         for a number of years on 22.5 mg of            told that for insurance reasons she was
levels while on divalproex. What is hap-        mirtazapine per night.                         changed to Paxil, and recently for the
pening through the prior authorization                                                         same reason changed to Celexa. It is not
process? I found one company “Navitus           A lower dose did not work and she
                                                                                               possible to prove that the medication
Health Solutions” on the Internet listing       complained of problems with the 30
                                                                                               changes resulted in hospitalization but
the purposes of this process:                   mg dose. Her Medicare part D pro-
                                                                                               it is certainly possible. The hospitaliza-
                                                gram would only allow her 30 pills per
                                                                                               tion, by my estimate, cost $20,000. She
• Increase appropriate utilization of cer-      month, although this is a cheap, generic
                                                                                               was stabilized and discharged on venla-
  tain drugs                                    medication. To get to her dose she needs
                                                                                               faxine. APA guidelines clearly state that
• Promote treatment or step-therapy pro-        45 pills. She pays for 15 pills by herself
                                                                                               antidepressants are not interchangeable
  tocols                                        and pays the co-pay to this company
                                                                                               for individual patients.
• Actively “risk manage drugs” with seri-       for the other 30 pills. I have appealed
  ous side effects                              to her Medicare part D carrier and it        These are only three examples of patients’
• Positively influence the process of           was denied. Subsequently I attempted         stories over the past year. Many patients
  managing drug costs                           to have it investigated through CMS.         have had psychoactive medications
                                                Nothing has changed in this situation        changed because of insurance or formu-
I also had the prior authorization form,        over the past year. What is this new         lary issues. One of my patients brought
which a psychiatrist gave me, from              restriction that counts your coverage as     me a simple letter from Medico stating
Navitus Health Solutions for Cymbalta.          the number of “pills” given per month?       that they “no longer will cover Effexor”
To allow the possible use of Cymbalta the       What enterprising MBA came up with           and asked her to talk to her doctor about
form states that Effexor XR, fluoxetine,        this approach to save money?                 alternative medications. Again these med-
citalopram, amitriptyline, and paroxetine                                                    ications are not interchangeable without
all need to be tried with dose, duration        Case Two: A young patient with schizo-
                                                                                             a risk of relapse. I have no knowledge
and side effects to be listed on the form.      phrenia was hospitalized on a police
                                                                                             of whether individual patient response
The best science, to date, is that if over      hold for dangerous behavior. He was
                                                                                             is a clinical issue with statins, calcium
months to years a patient has failed five       treated with three different atypical
                                                                                             channel blockers or other non-psychiatric
antidepressants, their needs are beyond         antipsychotics during his hospitaliza-
                                                                                             medications. Perhaps we should err on the
Cymbalta, they are candidates for VNS           tion for various clinical reasons. He
                                                                                             side of patient stability. Many psychoac-
therapy—which, to date, most insurance          was discharged stabilized on Zyprexa, a
                                                                                             tive medications such as antipsychotics,
companies have also denied. There is            nonpreferred agent for Medicaid since
                                                                                             antidepressants, and antianxiety agents
little doubt that the major driving force       July. His prescription for Zyprexa was
                                                                                             are not interchangeabale. Can we practice
behind formularies is cost containment.         refused by the pharmacy. The outpa-
                                                                                             our specialty?
The reason fluoxetine became preferred          tient physician had not yet seen him
in the Wisconsin Medicaid program was           and the inpatient physician had not
that it was the first SSRI to become avail-     known about the pharmacy’s failure to
                                                                                                                      continued on page 15

                                                                                                                       WINTER 2006 - 2007

Dual Diagnosis continued from page 5
ally stable. Support persons can also be
very valuable in reporting the benefits
                                              Letter to the Editor
and adverse effects of medications. The       Response to The Public Mental Health               This program was recognized by the Robert
psychiatric provider can request (from        System’s Mission: What It Is…and Isn’t             Wood Johnson Foundation. We became
the support staff) documentation of symp-     by James Hill                                      the project officers for the RWJ Program for
toms or side effects, and reports of how      (From the Wisconsin Psychiatrist,                  the Chronically Mentally Ill. In 1986-1987
these things differ in different settings     Summer-Fall, 2006)                                 Columbus, Ohio, was one of the nine grant
(work, recreation, home).                                                                        recipients cited by Meg Kissinger in the
In summary, individuals with develop-                                                            Milwaukee Journal. They used both RWJ and
                                              In James Hill’s recent article, “The Public        HUD money to construct a wonderful com-
mental disabilities are as susceptible to
                                              Mental Health System’s Mission: What It            munity housing program for the mentally ill as
mental illness as any other person is, and
                                              Is…and Isn’t,” he states, “There are more          well as support programs. All nine recipients
they can and do benefit from treatment for
                                              than enough mandates and failures we need          had to have a major housing component.
their mental illness. The dual diagnosis
of developmental disability and mental        to address. Low-income housing, develop-
                                              ment (my emphasis) and the eradication of          Milwaukee did not receive a grant. There
illness can present challenges to accurate
                                              poverty, however, is not among them.” I great-     were at least two major reasons Milwaukee
diagnosis and treatment. However, with
                                              ly respect the work that Mr. Hill is doing and     did not get in on this type of program 20
careful history taking, thorough docu-                                                           years ago. First, Milwaukee lacked a Central
                                              recognize the pressures he is under. But I
mentation of symptoms and treatment                                                              Authority to plan and coordinate such a com-
                                              would like to disagree with him with regard to
effects, appropriate use of treatments and                                                       munity program: everything in Milwaukee was
                                              the development of housing for the mentally
effective use of support teams, successful                                                       fragmented. There was not good continuity
                                              ill. Let me offer a little background reason for
treatment is not only possible, but often                                                        of care. Second, there was not a private non-
                                              this disagreement.
life-changing for the individual and pro-                                                        profit corporation whose primary responsibility
fessionally satisfying for the provider.      In 1967, as the Center Director of a pub-          was developing a broad-based continuing
Editing by Howard Mandeville, Wisconsin       lic sector mental health center in Boston          care program and no corporation willing or
Council on Developmental Disabilities         (Massachusetts Mental Health Center) my            able to take on the housing. Milwaukee has
                                              colleagues and I recognized that with deinsti-     never been able to really think through how to
and Jeff Marcus, MD, Central Wisconsin
                                              tutionalization, patients needed a system of       provide continuity of care in the community –
Center. Written with consultation by mem-
                                              care in the community that replaced and was        one system of care.
bers of the Wisconsin Mental Health and
                                              better than what they had in the long-term
Developmental Disabilities Workgroup.
                                              state hospital. They needed food, clothing,        In my opinion, housing for the mentally ill
                   ***                        housing, medical support, psychiatric atten-       will not be solved in Milwaukee unless the
                                              tion, socialization, rehabilitation programs       Behavioral Health Division first takes on the
Nancy Shook, RN, LCSW, APNP,                                                                     leader role in a truly centralized function.
                                              and a continuing care team. To meet these
works at the UW Waisman Center TIES                                                              Second, it must build a single community sys-
                                              needs, we in the public sector set up an inde-
Community Outreach Programs and               pendent, nonprofit corporation called Vin Fen.     tem that replicates in the community the func-
TIES Clinic. She may be contacted at          This mental health corporation contracted          tions served by the state hospital, including a
608 .265.9438 or             with local, state and federal agencies and         housing component. The rights of patients to
For more information about the                nonprofit organizations to provide a variety       live community life in accord with their highest
Workgroup, contact Chris Patterson:           of community services. It was apparent to us       level of functioning must supersede the legal                  that housing was essential. So, with leader-       right simply to a least restrictive environment.
                                              ship from the public sector, we developed a        Third, each deinstitutionalized patient must
For information about use of psycho-          variety of housing options including group         receive a total treatment and rehabilitation
tropic medications by persons with develop-   homes, co-op and supported apartment living,       plan coordinated by a single agency that
mental disabilities, see:    and independent apartment living, as well as       includes housing. Each component piece
tions/noeasyanswers.pdf.                      a few foster care placements. Much of the          must be accountable to a coordinating central
                                              funding came from contracts with the federal       authority.
For information about developmental dis-      Housing and Urban Development (HUD).
abilities and resources see: www.familyvil    Others came from commitments by local and          Jon E. Gudeman, MD or                 state housing and authorities and supple-          Former Medical Director and Administrator
                                              ments (Section 8s) to reduce rent.                 Milwaukee County Mental Health Complex

The Wisconsin Psychiatrist

A Psychiatric Perspective Addressing the Roots of Violence
in Milwaukee
Senseless Acts of Violence Point to Need for Prioritizing Mental Health, and
Promoting Professional and Community Interventions in Small and Large Ways
by Michael Bell, MD, and Fannie LaFlore, MS, LPC, CADC-D

                      The headline of          would have started eighth grade when          early ages.
                      a September 1,           school resumed September 5.
                      2006, article in the                                                   The family inevitably suffers in other
                                               In the aftermath of such senseless vio-       countless ways. Women are left to raise
                      Milwaukee Journal-
                                               lence, our deepest fears of living in an      children alone. A child doesn’t see his
                      Sentinel had a
                                               unsafe community are magnified. The           or her father for years, if at all, due to
                      common refrain.
                                               next day, individuals designated as leaders   expenses that can become overwhelming.
                      It pointed to the
                                               protest. Someone like Alderman Michael        To visit a loved one in jail or the cemetery
                      senseless violence
                                               McGee is willing to stand up and speak        at an early age is an experience that,
                      that continues to
                                               out, while so many other public servants      unfortunately, many people of darker hues
                      end innocent lives
                      in      Milwaukee:       go about their business. McGee always         have had to find ways to bear.
“‘Shots came out of nowhere’ as promis-        tells youth to “stop the violence.” Some
                                               listen, while others cannot hear. As old-     African-American women have had the
ing student sat on porch, her friend says.”                                                  special task of being the primary teach-
                                               time people sometimes used to say: “They
With the frequency of violence that rips       hear, but deaf.”                              ers of our youth. It’s amazing how most
through our community, each new inci-                                                        manage to do the job well despite many
dent brings about the same responses after     By mid-August of 2005, when Milwaukee’s       obstacles based on the current social and
the initial shock wears off: outrage, then     homicide toll reached 88, the commu-          cultural environment. When we’ve been
resignation. For some, there is also a feel-   nity was especially alarmed by this wide-     approached to comment on various social
ing of helplessness. For others, it becomes    spread and senseless loss of life, particu-   problems, the most common question is
despair. Most victims, families and per-       larly when placed in the context that this    essentially, “How can we keep our san-
petrators directly affected by this “street”   number was equal to the count for all of      ity, when all around us people are losing
violence live in or around the central city,   2004. America remains the most violent        theirs?”
near addresses that become increasingly        country in the world. African-American
familiar: 26th and Vliet, 6th and Hadley or    families continue to bear the heaviest        It is our view that senseless violence can
45th and Locust, for example. In the after-    burden of consequences associated with        be deemed a result of a special kind of
math, a predictable sequence of events         “street” violence. It is well-documented      insanity. Neuropsychiatric research has
unfolds. “Did you hear? Sharon’s son was       that a black male is 40 times more likely     suggested that the frontal lobe of the
shot last night. Two men drove by and          to be a victim of a gun shot wound than       human brain takes almost two decades
shot him in the leg and chest. I think they    his white counterpart, and more likely to     to fully develop and mature. How does
pronounced him dead at the scene.”             go to jail than college.                      this potentially relate to violence? The
                                                                                             frontal lobe has been called the “CEO of
The most recent example took place             What often gets under-reported are the        the Brain.”
around 11 p.m. on Wednesday, August            long-lasting consequences to families
30. It involved Candace Moss, a teenager       when someone is murdered or goes to jail.     In particular, the pre-frontal cortex is
shot in the chest by errant bullets, accord-   People are forever changed by exposure        associated with executive functioning,
ing to police, as she stood in front of her    to senseless deaths, imprisonment and         meaning that it deals with our ability
neighbor’s house in the 5300 block of N.       other burdens beyond what newspaper           to appreciate consequences, to plan for
39th St. The newspaper article quoted          headlines reveal. The tears are countless     future events, to understand and integrate
a friend, Amber Cotton, 20, as saying          for families of those who are killed and      a proper sequence of activities for goal-
that ‘out of nowhere’ as many as 15 to         those who kill. The loss of fathers, sons,    directed behavior. This part of the brain
20 shots were fired. This past June, the       mothers and daughters can affect relatives    is very sensitive to injury through alco-
victim had received “Good Citizen” and         for years. Children are scarred in many       hol, direct trauma and various psychiatric
“Outstanding Math Student” awards from         ways, and their innocence shattered when      disorders. When this part of the brain is
John Muir Middle School, where she             they are exposed to significant violence at   injured or compromised, people tend to

                                                                                                                    WINTER 2006 - 2007

become more impulsive.                           more substantial underlies their destruc-      Addressing impulsivity is a start, and
                                                 tive feelings, thoughts and behavior. In       there are various other means. We all can
Impulsivity, in our opinion, is a com-
                                                 fact, violence has become so common in         help the people we serve in removing risk
mon factor in most violent acts. Imagine         some communities that most people do           factors.
this scenario: A 15-year-old male with a         not even recognize it as a symptom of
history of witnessing violence and per-                                                         If we know guns increase the risk of
                                                 mental health issues.
haps abusing alcohol finds a Raven-25                                                           impulsive violent acts, let’s remove the
handgun (a popular model in Wisconsin).          We suggest that senseless violence is a        guns. We applaud the efforts of local civic
Already, we have the breeding ground for         signal of something underneath the sur-        leaders in the recent “buy back the guns”
violence.                                        face that is very wrong, a pathological        program that was launched in recent sum-
                                                 state when it is not self-defense or carried   mers. Since alcohol impairs the ability to
A closer look at the scenario above reveals      out during a war, for example.                 ponder and consider one’s actions, let’s
at least five risk factors for impulsivity and                                                  help our patients recover from substance
violence. These include an undeveloped           A fever, for example, is a sign that some-
                                                                                                abuse and dependence.
prefrontal cortex secondary to the young         one may have anything from a simple
man’s age, and the fact that we know             cold to an allergic reaction or even possi-    Health care professionals and support
males are typically more aggressive. He          bly cancer. It means that something needs      staff, faith- and community-based orga-
has witnessed violence and is abusing            to be addressed in most cases. Violence        nizations providing treatment and support
alcohol, both of which lead to poor blood        also is a powerful signal that something       services, and other public health officials
flow to the prefrontal cortex, again lead-       needs to be addressed in more depth. It’s      can become part of a first-line of defense
ing to impulsivity. He also has access to a      easy to preach “stop the violence” and         if we notice details that might indicate
handgun, one of the most impulse-driven          other surface comments that do not begin       that something is wrong in the life of a
instruments of death known to mankind.           to deal with why individuals are so care-      child, youth or adult.
It takes fractions of a second to form a         less, in feeling, thought and action.
                                                                                                Physicians who provide yearly physicals
thought of hurting someone else or your-         Many areas need to be addressed to reduce      can share information about their career as
self, and then pulling the trigger.              violence, including education, econom-         a way to encourage a positive self-concept
When we talk about people killing other          ics, politics (poli-tricks) and family life,   in youth. Something as simple as shar-
people, we often find ourselves engaged          among others.                                  ing our professional training background
in conversations about policies, legal and                                                      might spur someone to consider health
                                                 It is easy to determine, for example, the
socioeconomic issues, cultural and ethical                                                      care work as a future option. Front-desk
                                                 direct consequences of years of untreated
concerns. Surely these factors are valid                                                        staff might find something to compliment
                                                 high blood pressure. A stroke might be
and have implications.                                                                          a child about if they notice someone who
                                                 among the severest outcomes. Few may
                                                                                                looks sad or withdrawn. Other staff might
However, if we look at individuals and           be surprised when one considers an indi-
                                                                                                engage a youth in brief conversation by
violent incidents as a study of human            vidual’s medical history, years of high-salt
                                                                                                asking questions of interest when they’re
behavior, we find that as you increase the       diets, no exercise, smoking and obesity as
                                                                                                at the clinic while waiting for a parent
number of factors that relate to impulsiv-       contributing factors.
                                                                                                during an appointment.
ity, you increase violent acts. Although         What, in comparison, are the equiva-
                                                                                                It’s often easy to dismiss a kid or youth
such impulses border on insanity, it does        lent consequences of years of depres-
                                                                                                who appears to be unruly or disrespect-
not necessarily equate to someone being          sion, anxiety, isolation, substance abuse
                                                                                                ful in their interactions with siblings or
deemed not responsible for their actions.        and trauma? How can we as a commu-
                                                                                                adults, or to belittle their potential based
On the contrary, promotion of mental             nity play a role in removing the threat
                                                                                                on stereotypes that suggest some youth
health requires that we are held account-        of impulsive violent acts from our com-
                                                                                                only have interest in basketball or rap.
able. People always have choices in any          munity? An understanding of risk factors
                                                                                                But what if we took a closer look at the
given situation. Most consider options           for violence, and the ability to respond
                                                                                                many opportunities, some fleeting and
other than violence. Most think of poten-        with both preventive tools and resources
                                                                                                some longer in duration, when we have
tial consequences prior to acting out their      for intervention in a timely manner, can
                                                                                                moments to enforce positive self-concepts
impulses of anger and frustration.               give us the power to help save lives in the
                                                                                                in young people who may rarely get posi-
Many view violence in our community                                                             tive reinforcement?
as simply normal. Most perpetrators are          Violence is but one symptom, and a
simply labeled “criminal” as if nothing          consequence of years of mental unrest.
                                                                                                                         continued on page 14

The Wisconsin Psychiatrist

Milwaukee continued from page 13
Health care, if looked at from a lifespan     Symptoms of this psychological pain are        It cannot just be African-American women
and quality-of-life perspective, should       manifest through feelings, thoughts and        alone. It needs to be all of us in different
involve both consideration of physical        behavior, and the routine way that news        ways, or the cycle of violence will haunt
and mental health needs, as well as take      media cover such incidents of sense-           everyone to some extent, and despair will
into consideration the socioeconomic and      less violence cannot fully describe how        replace hope for too many, for too long.
environmental factors that can affect the     deep the wounding goes. When a reporter
                                                                                             Michael Bell, MD, is Director of
functioning, well-being and self-concept      interviews the mother of a victim, we wit-
                                                                                             Behavioral Health at Milwaukee Health
of a child or adolescent. Given the recent    ness the immediate aftermath of a painful
                                                                                             Services Inc., a community health cen-
increases in violence and other forms of      experience, with tears rolling down her
                                                                                             ter in Milwaukee’s central city, and
dysfunction noted among many young            face. The mother, along with her extended
                                                                                             also an Assistant Clinical Professor
people we serve in our communities, it’s      family, may have been sitting on a porch
                                                                                             of Psychiatry and Behavioral Science
important not to overlook the variety of      during the interview. When media leaves,
                                                                                             at the Medical College of Wisconsin.
factors that can impact their daily lives     she goes back into her house, still in shock
                                                                                             Fannie LeFlore, MS, LPC,CADC-D, is
and the small ways we might be able to        and disbelief. Friends offer to cook, clean
                                                                                             a Licensed Mental Health and Substance
have some impact on their choices and         and solicit funds to help with expenses for
                                                                                             Abuse Counselor and Owner/President of
future potential.                             burial and other immediate family needs.
                                                                                             LeFlore Communications, LLC, a small
                                              Nourishment of the spirit is often an
Behavioral Health or Behavioral Science                                                      business based in Milwaukee that offers
                                              afterthought. The protection of the mind
is the study of how human beings behave                                                      expertise and professional services in
                                              is considered a luxury. It all comes at the
as individuals and within groups and                                                         Corporate Communications Consulting
                                              expense of mental health.
cultures; what influences the way people                                                     and Special Projects in Business and
think, feel and act; what roles people play   Violence is in many ways predictable           Human Services.
when they are members of a group; why         and treatable, if we all take seriously the
groups value certain ideas, customs and       symptoms people show in our families
traditions; what factors determine how        and communities before the last and final      Dr. Bell’s contact information is: 8200
individuals develop their identity, values    sequence of events erupt that lead to          Silver Spring Ave., Milwaukee, WI
and character and how we deal with those      violence. This does not mean attempting        53218. 414.760.3953/414.264.7995;
who are different, in addition to other       to become Good Samaritans in ways that
broad issues of importance in society.        put ourselves or our own families and
                                              neighbors at risk of harm. But we can act      Fannie LeFlore’s contact information
Certainly, professionals in primary and                                                      is: LeFlore Communications, LLC, PO
                                              to intervene in meaningful ways beyond
behavioral health care cannot be every-                                                      Box 18376, Milwaukee, WI 53218-0376;
                                              what has become routine in attempts to
where, but by including general questions                                          ;
about academic interests and self-concept                                                    414.438.1534 office; 414.526.0908 cell
perceptions related to overall well-being     We believe victims of violence and their       phone.
when we examine or evaluate youth dur-        families deserve more than teddy bears
ing an appointment, we can get better         and flowers at crime scenes. Families
clarity about an individual’s mental state    forced to deal with violence deserve
at a given time. We can offer support,        access to mental health treatment, psycho-
make referrals and do follow-up with          logical and other practical support from       Election Update continued from page 9
clients. We can make greater attempts to      the community, and should not be simply
communicate with their parents, teachers      stigmatized as non-human.                      Originally, the committee planned to pre-
and youth workers who influence the lives                                                    pare a report to the legislature by the end
                                              Violence will likely always be with us in
of clients we serve.                                                                         of May but formally set a deadline of
                                              one form or another, but our reaction to it
In addition to preaching “stop the vio-       should evolve from simply watching the         September 13. On that day, the Senate
lence,” we have to provide adequate           news and shaking our heads in dismay, to       Organization Committee voted 3-2 along
resources and support to promote healing      actually doing something about it through      party lines to delay final action until
after violence and prevention before it       daily actions on both a small and large        December 5.
takes place. The bottom line is that, no      scale. After the news cameras leave, who
matter the underlying cause of violence,      will respond to the unmet needs of the
the consequence is always the same:           victims and families that will suffer con-
psychological pain.                           sequences for years to come?

                                                                                                                  WINTER 2006 - 2007

Editorial: De Facto Clinical Regulation by FDA
Once again, doctors, it is time to advocate for your patients
By Laurens D. Young, MD
                                                would like to investigate these important     then what? Prescribe valium, thyroid,
                                                clinical problems scientifically and turns    stimulants or antihistamines as was prac-
Recent rulings by the US Food and Drug
                                                them to less cumbersome pursuits.             ticed 50 years ago? It would seem to me
Administration and other governmental
                                                                                              that we owe a little more concerted cog-
bodies remind us that despite all the           This is not the first time that the FDA       nitive activity to our patients and to our-
scientific progress of the past 50 or so        has plunged a “black box” into customs        selves. The governmental urge to regulate
years in psychiatry, it is still necessary      and standards of psychiatric care. Last       industry rather than protect patients ought
to remind others that psychiatry really         year the FDA notoriously issued a cau-        to be pointed out and challenged along
is the practice of medicine. As I am            tion on nine antidepressants (SSRIs and       with the diffidence and unwillingness
now mainly a geriatric psychiatrist, I          others) noting increased suicides in tri-     of the drug industry to work positively
read with interest a recent New England         als. Collectively such events send a chill    on major psychiatric problems. I cannot
Journal of Medicine publication derived
                                                through practices and jeopardize phar-        imagine these approaches to groups of
from the CATIE study which tested three
                                                macological firm interest in psychiatric      internists or surgeons. Change is unlikely
“atypical” antipsychotic agents for psy-
                                                issues. Now, having cast a pall over the      to come about without strong advocacy on
chosis in elderly patients with advanced
                                                most effective class of medication for        the part of psychiatrists.
Alzheimer’s disease against placebo. The
results, I thought, were encouraging, as        late adult psychosis and the most popular
                                                                                              I am not certain what mechanisms the APA
they confirmed (with some study imposed         classes for juvenile affective disturbance,   may have for moving on these issues, but
limitations) my general experience that         does this mean the FDA will start looking     it should be brought to their attention in
these drugs were effective in reducing          for problems with previously acceptable       a forceful and timely manner. Left alone,
“psychotic” symptoms in the elderly and         treatments for young and middle-aged          the stripping of psychiatry of its ability to
had side effects that could often be man-       adults? Even if further reviews of trials     intervene effectively will not get better
aged with dose changes or discontinua-          preserve the initial impressions that the     and probably will get a great deal worse.
tion. The authors, however, commented           newer antidepressant and antipsychotic        Have your residents and students ever
that the benefits were statistically “offset”   are generally effective and safe, the seeds   asked you about an identity crisis? Tell
by the adverse effects. Almost no attention     of doubt have been planted in the public      them to stay tuned; organized psychiatry
was paid to the finding (somewhat limited       mind by these actions that amount to          appears to be having one.
by the small number of patients—around          retrospective embargoes. The common
400) that there was no difference in seri-      factor is that the FDA and other regulator
ous adverse effects such as falls, deaths       agencies took it upon themselves to draw
                                                                                              Formulary Mess continued from page 10
and cerebrovascular events between pla-                                                       I have thought of one avenue that psychia-
                                                sweeping conclusions based on a small
cebo and trialed drugs.                                                                       trists may want to pursue: Legislation,
                                                bunch of studies that were designed for
                                                                                              at the state level, that would attempt to
The latter omission is important because        much more modest decision making, and
                                                                                              mandate insurance companies to accept
earlier this year the FDA issued a “Black       the public does not understand what a
                                                                                              the following:
Box” Caution on the use of newer anti-          drug “indication” really means.
psychotic agents in dementia because a                                                        A new enrollee’s psychoactive medica-
                                                The collective response of leadership of      tions are to be treated as “preferred” if
review of previous trials had revealed an
                                                our representative organizations to these     they have been on the medications for
increase in deaths and serious adverse
                                                assaults on our profession (and by exten-     over 6 months.
events in this population. The mass media
                                                sion on our patients by depriving us of
however had plenty to say: concluding                                                         Any enrollee that has been stabilized dur-
that antipsychotics were of little use, were    important tools) has been embarrassingly
                                                passive. Staying silent is as good as say-    ing inpatient psychiatric treatment would
not indicated, and created the impression                                                     have their discharge medications treated
that any use no matter how carefully con-       ing “Oh, just take in all the negative
                                                propaganda you can and try to explain the     as “preferred.”
sidered and monitored was risky It has
been alleged that this kind of publicity has    very sophisticated and convoluted statisti-    What do other WPA members think? Are
brought a stop to drug company interest in      cal reasoning required to make a decision     there other thoughts on how to approach
testing these issues for fear of law suits.     about risks and benefits of treatment in      this problem which impacts so many of
It certainly puts a damper on those who         your next 15 to 20 minute session.” And       our patients?

The Wisconsin Psychiatrist

WPA Spring Conference March 30-31, 2007
Assessment and Treatment of Aggressive Behavior
By Kenneth Casimir, MD, Program Chair
                        Most psychiatrists       over 450 published articles, abstracts,        The Saturday morning portion of the
                        and other mental         reviews, books and book chapters.              scientific program will focus on the treat-
                        health profession-                                                      ment of sexually violent predators (SVPs).
                                                 The scientific program will be divided
                        als will encoun-                                                        We are very fortunate to have two of the
                                                 topically into three main portions: Friday
                        ter violence and                                                        authorities in this field, with national
                                                 morning, Friday afternoon and Saturday
                        aggressive behav-                                                       and international reputations, practicing
                                                 morning. Each topic area will begin with
                        ior in their patients,                                                  in Wisconsin. They have agreed to con-
                                                 presentations by individual speakers, fol-
                        either directly or       lowed by panel discussions with encour-        tribute to our program as faculty mem-
                        indirectly. This may     agement of audience participation. Friday      bers. Dr. Dennis Doren, Director of the
                        include inpatient        morning’s principal speaker will be Dr.        Sand Ridge Assessment Unit, and author
                        management of a          Steiner, who is expected to focus primar-      of Evaluating Sex Offenders: A Manual
patient who exhibits aggressive behavior,        ily on the Psychobiology of Aggression         for Civil Commitments will begin with a
assessment of dangerousness in a clinical        and Theoretical Models of Aggressive           presentation on the assessment of sexu-
or forensic context, or outpatient treat-        Behavior.                                      ally violent predators. Following this, Dr.
ment of patients with symptoms that may                                                         David Thornton, Clinical Director of the
contribute to violent behavior. In the inter-    Friday afternoon will focus on the treat-      Sand Ridge Secure Treatment Center in
est of confronting this topic in an informa-     ment of aggressive and violent behavior        Mauston, will discuss the treatment of
tive and relevant manner, the scientific         in two of the most secure psychiatric          sexually violent predators. Dr. Thornton,
                                                 treatment facilities in Wisconsin: Mendota     originally from England, enjoys an inter-
program at the WPA Annual Conference
                                                 Juvenile Treatment Center (MJTC), and          national reputation in this area, and we
in 2007 will focus on the assessment and
                                                 the adult Forensic Program at Mendota          are extremely pleased at his participation
treatment of aggressive behavior. Faculty
                                                 Mental Health Institute. Presenting first      in our 2007 scientific program. Following
for the program will include clinician
                                                 will be Gregory Van Rybroek, PhD, JD,          the customary panel discussion, the pro-
researchers with national and interna-
                                                 and Michael Caldwell, PhD.
tional reputations, as well as distinguished                                                    gram is scheduled to adjourn by noon on
experts from within our own state who            Drs. Van Rybroek and Caldwell will dis-        Saturday.
are charged with treating the most violent       cuss the assessment and treatment of
                                                                                                We invite all WPA members, their fami-
psychiatric patients in Wisconsin.               severe conduct disorder and comorbid
                                                                                                lies and guests, and all other colleagues in
                                                 psychiatric illness in a correctional/clini-
The program this year will be held in                                                           psychiatry and related mental health pro-
                                                 cal environment.
a new venue, the Osthoff Resort on                                                              fessions to the WPA 2007 Annual Meeting
Elkhart Lake. Activities will begin on           Data from a number of funded studies at        on March 30-31, 2007. Join us for a truly
Friday morning with a continental break-         MJTC has shown remarkable success in           world class scientific program right here
fast and opening of the display area.            reducing antisocial behavior and psychiat-     in southern Wisconsin at the stylish and
WPA President Edward Krall, MD, will             ric recidivism in the juvenile population.     relaxing Osthoff Resort on lovely Elkhart
launch the scientific program with open-                                                        Lake.
                                                 The second portion of the afternoon will
ing remarks at 8 a.m. The keynote speaker        consist of a presentation by Brad Smith,       Additional details will be contained in
for this year’s conference will be Hans          MD, on the pharmacologic management            the final program and registration materi-
Steiner, MD. Dr. Steiner is a Professor of       of violent behavior. Dr. Smith is the          als, which will be sent via mail in early
Psychiatry and Behavioral Sciences, Child        Clinical Director of the Forensic Program      2007, and at the Wisconsin Psychiatric
Psychiatry and Child Development at the          at Mendota Mental Health Institute, and        Association Web site:
Stanford University School of Medicine.          as such is responsible for the clinical care
Dr. Steiner is considered an international       of some of the most violent, psychiatrical-    See page 17 for the preliminary sched-
expert in three areas: 1. Aggression and         ly ill patients in Wisconsin. His course on    uled topics and speakers for the 2007
its relationship to psychopathology, 2.          the management of aggressive behavior          Conference.
Psychopathologies associated with trau-          at APA Psychiatric Services is tradition-
ma and victimization, and 3. Pediatric and       ally sold out, and a very popular offering
psychiatric comorbidity. He has authored         within the APA curriculum.

                                                                                           WINTER 2006 - 2007

WPA Annual Meeting: Assessment and Treatment of Aggressive Behavior
(Preliminary Schedule)
Friday, March 30
8 a.m.               Welcome and Introduction           3:30 p.m.            Break
8:15 a.m.            Psychobiology of Aggression        3:45 p.m.            Pharmacologic Treatment of
                     Dr. Hans Steiner                                        Aggression
9:15 a.m.            Theoretical Models of Aggressive                        Dr. Brad Smith
                     Behavior                           4:45 p.m.            Panel Discussion
                     Speaker (TBA)
10:15 a.m.           Break                              Saturday, March 31
10:30 a.m.           Aggression and Its Relationship    8 a.m.               Welcome and Introduction
                     to Psychopathology                 8:15 a.m.            Assessment of Sexually Violent
                     Dr. Hans Steiner                                        Behavior
11:30 a.m.           Panel Discussion                                        Dr. Dennis Doren
Noon – 1:30 p.m.     Lunch                              9:30 a.m.            Break
1:30 p.m.            Aggressive Behavior in             9:45 a.m.            Treatment of Sexually Violent
                     Adolescents – MJTC                                      Predators
                     Dr. Michael Caldwell                                    Dr. David Thornton
2:30 p.m.            Treatment of Aggression in         11 a.m.              Panel Discussion
                     Dr. Greg Van Rybroek

  PSYCHIATRIST WANTED                                     2006 Membership
  Psychiatrist needed to work with chronically            Transactions
  mentally ill consumers in La Crosse County              October-November
  Community Support Program (CSP). Hours
  are 24-40 hours per week depending on phy-              New MIT
  sician’s preference. No nights or weekends,             Rebecca Harrison, MD
                                                          Medical College of Wisconsin – Milwaukee
  and no on-call responsibilities. An attractive
  salary with benefits included at 32 hours               R. Christopher Moore, MD
                                                          UW School of Medicine and Public Health
  per week. Submit cover letter and CV to:
                                                          Jessica Taylor, MD
  Paul Brown, Clinical Coordinator
                                                          Medical College of Wisconsin – Milwaukee
  Family and Children’s Center
  1707 Main St.                                           Robert J. Vicrey, MD
  La Crosse, WI 54601                                     UW School of Medicine and Public Health
  Phone: 608.785.0001
  Fax: 608.785.0002                                       Reinstate and Upgrade to GM
  E-mail:                            Vani Ray, MD                                      New GM
                                                          Maria I. Mas, MD

The Wisconsin Psychiatrist

Calendar of Professional
& Clinically Oriented Events
December 7-10, 2006                                              March 30-31, 2007
American Academy of Addiction Psychiatry                         2007 Annual Conference
Don CeSar Beach Resort                                           Wisconsin Psychiatric Association
St. Petersburg, FL                                               Osthoff Resort
                                                                 Elkhart Lake, WI
March 1-4, 2007
2007 Annual Meeting                                              April 27-28, 2007
American Association for Geriatric Psychiatry                    2007 Annual Meeting
New Orleans, LA                                                  Wisconsin Medical Society
                                                                 Monona Terrace Convention Center
March 2-3, 2007                                                  Madison, WI
Spring 2007 Psychiatric Update
UW School of Medicine and                                        May 19, 2007
Public Health and Madison Institute                              American Psychiatric Association
of Medicine, Inc.                                                Annual Meeting
Monona Terrace and Convention Center                             San Diego Convention Center
Madison, WI                                                      San Diego, CA

Note to readers and publicists: If you wish to have a professional meeting listed in future issues of the Wisconsin Psychiatrist,
please send it to the Editorial Office, WPA, PO Box 1109, Madison, WI 53701, Fax 608.283.5424.

Wisconsin Psychiatric Association
PO Box 1109
Madison, WI 53701

 Inside this Issue:
  One Size Fits One
  By Chris Murano, MD.......................................1
  Saying Good-bye to Ed Levin
  By Randall Lembrecht, PhD.............................2
  President’s Comments
  By Edward Krall, MD........................................3
  The Other Dual Diagnosis: Part 2
  Nancy Shook, RN, LCSW, APNP.....................5
  Podcasting: Part 2
  By S. G. Zelinski, DO, PhD...............................6
  Medicaid: Atypical Antipsychotics
  By Harold Harsch, MD.....................................8
  Election Update
  By Michael Blumenfeld....................................9
  Editorial: The Formulary Mess
  By Harold Harsch, MD...................................10
  Addressing the Roots of Violence in Milwaukee
  By Fannie LaFlore, MS, LPC, CADC-D..... ....12
  Editorial: Regulation by the FDA
  By Laurens D. Young, MD..............................15
  Spring 2007 Conference Overview
  By Kenneth Casimir, MD...............................16
  Spring 2007 Conference Schedule in Brief..17

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