Psychiatry Department impacts entire state with broad range of programs

Telepsychiatry, novel research, mental health recruitment among initiatives

Steven Wengel, M.D.

Chair: Steven Wengel, M.D.

No. of people in department (faculty/staff): 19 physicians, 1 psychologist, 12 clinical staff, 29 clerical and administrative staff

Residents/fellows: 30 general residents, 5 child psychiatry fellows and 1 Post-Pediatrics Portal Program resident in the combined Creighton-Nebraska Psychiatry Residency Training Program
     

New programs:

• Clinic for Outpatient Psychiatry Education (C.O.P.E.):  a student-centered outpatient teaching clinic to teach third-year medical students how to interview under the direct observation of psychiatry faculty. In 2013, the clinic will explore the addition of psychiatric nurse practitioner faculty and trainees to create an interprofessional training model.
       
• Telepsychiatry:
   
  • Thomas Magnuson, M.D., has provided leadership and direct patient care for a novel clinical program which currently serves over 50 rural communities around the state. He provides access to a board-certified geriatric psychiatrist for rural nursing home patients with dementia-related behavioral problems, depression, delirium, and chronic mental illness such as schizophrenia and bipolar disorder. This unique service has received outstanding feedback from rural communities by providing state-of-the-art geriatric psychiatry assessment and treatment, which would otherwise not be available without transporting patients long distances to receive this care.
  • R-Way is a model telepsychiatry site providing psychiatric care to a mental health clinic in Wayne, Neb. Through this service, patients with chronic mental illness who would otherwise not have local access to a psychiatrist are able to receive psychiatric assessment, medication management, and problem solving advice. The patients are able to communicate to a faculty psychiatrist and psychiatric resident at UNMC via high-definition, HIPAA-compliant videoconferencing. Patients have liked this way of seeing a psychiatrist without having to travel many hours. It is also convenient for the staff at Wayne, who are not required to make road trips with the patient. It is a model that would be useful in other rural communities where psychiatrists are not readily available. 
  • Our newest telepsychiatry development is at Chadron State College. This outreach provides for the assessment and medication management of students with psychiatric needs by way of telepsychiatry. The connection is through a HIPAA-compliant network and provides a safe and secure way to see and hear the patient. The computer connection allows seeing the patient in real time. The patient can see the psychiatrist from his screen. There has been strong satisfaction for this type of service. The student does not have to travel to a distant clinic to receive treatment. The provision of telepsychiatric care in a rural setting is an important direction for Nebraska’s health future.
        
• Behavioral Health Education Center of Nebraska (BHECN):  Founded in 2009, BHECN’s mission is to recruit and retain the best students to enter mental health careers and to provide cutting edge training in behavioral health topics to primary care and mental health providers statewide. Howard Liu, M.D., a child & adolescent psychiatrist, is medical director of BHECN and co-leads the program with associate director, Brent Khan, Ed.D., and associate clinical director, Michael Rice, Ph.D.  The Department of Psychiatry has partnered with BHECN on three important initiatives:
   
  • Rural Psychiatry Training:  Integrating rural clinical sites and telepsychiatry into the psychiatry residency program.
  • Depression Modules:  Creating online curricula on depression for primary care and behavioral health providers which have been accessed across Nebraska and nationally in more than 40 states.
  • Ambassador Program:  Mentoring high school, college, and professional school students to consider mental health careers.
     
• Building Healthy Futures school-based mental health clinics: Child and adolescent psychiatry consultation is provided by two members of the Department of Psychiatry to three OPS elementary schools as part of the school-based health clinics’ partnership with Building Healthy Futures and OneWorld Community Health Center.
         
• Post-Pediatrics Portal Program: The Creighton-Nebraska Psychiatry Training Program is one of four training sites in the country to offer this unique opportunity. This training is designed for pediatricians who want to retrain in child and adolescent psychiatry and builds on a core set of skills from pediatrics training, expanding trainees’ expertise to integrate the core competencies in psychiatry and child and adolescent psychiatry. We provide an abbreviated structured training program for pediatricians from training programs accredited through the Accreditation Council for Graduate Medical Education to become eligible for certification in psychiatry and child and adolescent psychiatry (CAP) within a three-year time period. This involves spending the equivalent of 18 months in adult psychiatry rotations and programming, as well as 18 months in CAP rotations and programming.
              

Significant research grants/publications:

 
The department has a lengthy history of investigating novel treatments for major depression. These clinical studies are usually done as multi-center randomized, controlled trials and are important because 10-20 percent of people with major depression do not respond to available treatments. Two ongoing studies are presented as examples:

Synchronized Transcranial Magnetic Stimulation (sTMS): We are currently testing a new form of magnetic brain stimulation to treat depression using a new form of transcranial magnetic stimulation. This device generates a sinusoidal magnetic field set at precisely the average Intrinsic Alpha Frequency (IAF) calculated from the subject’s electroencephalogram (EEG).  The purpose of this study is to test whether this type of stimulation can be helpful for persons who have not responded to available treatments for depression.

Intravenous antidepressant therapy for refractory depression:   This study is the first large-scale investigation of a novel medication, given as an intravenous infusion, for persons who have not responded to other treatments for depression. This is an important study since the study compound has an unique mechanism of action that differs from all currently available treatments and may have a more rapid onset of action than oral medications.
        

Clinical trials in child & adolescent psychiatry

 
Current pediatric psychopharmacology trials are examining interventions for patients with ADHD, generalized anxiety disorder, and Fragile X syndrome. 

Computerized screening in adolescents with substance or psychiatric disorder. This study is comparing a clinician-administered diagnostic assessment via tele-video to a computerized version of the same diagnostic assessment. The trial is being conducted in partnership with the Center for Psychological Consultation in Madison, Wis., and is funded by the National Institutes of Health via a SBIR grant. 

Innovative studies of novel drug for subjects with Fragile X syndrome. We currently have four ongoing multi-center trials, two for adolescents and two for adults, to study the safety, efficacy and tolerability of a novel drug intervention at neuronal sites for the significant problem behaviors associated with Fragile X syndrome. Two of the trials, which began in 2010, are lead-in protocols followed by open label, long-term extension studies. These are important studies as our expertise was recognized by being among the very first sites recruited nationwide and for its ground-breaking research regionally seeking a target-specific treatment intervention of a hereditary developmental disorder without cure.
              

Collaborative research

 
PROTECT Study: This NIMH-funded study co-led by William Burke, M.D., psychiatry, and William Lydiatt, M.D., otolaryngology/head & neck surgery, was designed to investigate whether depression that occurs in the context of treatment for head and neck cancer can be prevented. This is an extremely important question since developing depression during the course of treatment can impact the long-term course of the underlying illness. This study has recently completed enrollment and its preliminary findings support the idea that prophylactic antidepressant can significantly reduce the rate of development of new cases of depression.

ABCDE Protocol Initiative at The Nebraska Medical Center:  Funded by the Robert Wood Johnson Foundation (Interdisciplinary Nursing Quality Research Initiative), this project is led by PI Michele Balas, Ph.D., College of Nursing, and Co-PI William Burke, M.D. It is designed to implement, analyze, and disseminate an evidence-based, nurse-led, inter-professional, multi-component program focused on improving the care and outcomes of critically ill adults in all of the intensive care units at The Nebraska Medical Center. The study has completed data collection, and preliminary findings suggest important positive effects on several important patient outcomes.
               

Alzheimer’s research

 
The department has a more than 20-year history of clinical trials for potential treatments for Alzheimer’s disease. Recent trials have investigated both passive and active immunotherapies to reduce the burden of beta-amyloid in the brain, as well as trials of small molecules aimed at disrupting key pathways in the disease. Additional studies have looked at ways to impact the behavioral symptoms of the person with dementia as well as lessen the burden on caregivers.
              

Other highlights:

 
Clinical outreach to:

• Omaha-area nursing homes through Geriatric Psychiatry Nursing Home Service;
• MOSAIC program for those with intellectual and developmental disabilities;
• Munroe-Meyer Institute;
• OneWorld Community Health Centers; 
• Charles Drew Clinic;
• UNMC SHARING Clinic;
• Lasting Hope Recovery Center;
• Omaha VA Hospital; and
• Winnebago Tribal Health Department.

Honors/Awards:  

• 2012 – Howard Liu, M.D., graduated from UNMC’s Technology in Educational Scholarship (TiES) Program.
• 2012 – Howard Liu, M.D., and Ashish Sharma, M.D., received the department’s inaugural Flint & Steel Teaching Awards in Educational Excellence & Educational Engagement.  
• 2011 – Howard Liu, M.D., and Dennis McNeilly, Psy.D., received the Outstanding Innovation in Medical Education Poster Award, Association of Directors of Medical Student Education in Psychiatry (ADMSEP).
• 2011 – Ashish Sharma, M.D., won the Hirschmann Prize for Teaching Excellence, a College of Medicine award given to a single clinical faculty member each year and reflecting unswerving dedication to educating UNMC medical students in clinical psychiatry.
• 2010 – Joan Daughton, M.D. named chair of the highest-rated Clinical Case Conference session at the annual American Academy of Child and Adolescent Psychiatry meeting, “The Wild Child: A Work in Progress.”  
• 2009 – Robin Zagurski received the Be Prepared Award for Excellence in Risk Communication from Nebraska Lt. Gov. Rick Sheehy.

Regional/National Committees:

• 2011 – Howard Liu, M.D., co-chair of the Training & Education Committee, American Academy of Child & Adolescent Psychiatry (AACAP).
• 2010 – Howard Liu, M.D., co-chair of the Clinical Simulation Initiative (CSI) Task Force, Association of Directors of Medical Student Education in Psychiatry (ADMSEP)
• 2009-present – Joan Daughton, M.D., president of the Nebraska Regional Council for the American Academy of Child and Adolescent Psychiatry. 
                 

Selected publications:

 
Textbooks:

Pediatric Psychopharmacology: Principles and Practice, 2nd Edition, Martin A, Scahill L, Kratochvil CJ Editors, Oxford Press, 2011.

Book chapters:

Wengel SP, McNeilly DP, Burke WJ: Depression in Parkinson’s Disease: In Parkinson’s Disease.  Edited by Ebadi M., Wszolek Z. Pfeiffer R.  CRC Press LLC, 2012

Abassi O, Burke WJ: Geriatric Depression. In Ham’s Primary Care Geriatrics, (6^th ed).  Edited by Warshaw GA, Ham RJ, Sloane PD, Flaherty E, Potter, JF. In Press. 

Scholarly articles:

Vaughan B, Kratochvil CJ (2012).  Pharmacotherapy of Pediatric Attention-Deficit/Hyperactivity Disorder.  Child Adolesc Psychiatr Clin N Am.  21(4):941-55

Kratochvil CJ, Vaughan, B, Stoner J,  Daughton, JM, Lubberstedt B, Murray D, Chrisman A, Faircloth J, Itchon-Ramos N, Kollins S, Maayan L, Greenhill L, Kotler L, Fried J March J (2011).   A Double-Blind, Placebo-Controlled Study of Atomoxetine in Young Children with ADHD. Pediatrics.  127(4)e862-868.

Liu HY, Potter MP, Woodworth KY, Yorks DM, Petty CR, Wozniak JR, Faraone SV, Biederman    J.  Pharmacologic treatments for pediatric bipolar disorder:  a review and meta-analysis.  The  Journal of the American Academy of Child and Adolescent Psychiatry 2011; 50(8):749-762.    

Cohen MZ, Holley LM, Wengel SP, Katzman M (2012). A platform for nursing research on spirituality and religiosity: definitions and measures. West J Nurs Res 34:795.

Corbett CF, Balas MC, Costa LL, Burke, WJ, Daratha, KB, Feroli, ER.  Trends in Interdisciplinary Research. Medical Care, In press.

Lydiatt WM, Bessette D, Schmid KK, Sayles H, Burke WJ: Prevention of Depression Using Escitalopram in Patients Undergoing Treatment for Head and Neck Cancer.  Submitted.