Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at editor@crisisnow.com.
Amy Cohen, Ph.D., director of SMI Adviser, says her resting state is optimistic. In 2017, after nearly two decades working at the United States Department of Veterans Affairs, she sought a new opportunity to push change in care for those with serious mental illness. “When I saw the call for SMI Adviser, I thought, ‘Oh, this is something that could make a difference,’” she says. “It would allow me to be noisy.”
Grant funded by SAMHSA and administered by the American Psychiatric Association, the initiative provides free evidence-based clinical and technical assistance to teams who care for people with serious mental illness. “We define care teams broadly,” highlights Dr. Cohen. That includes psychologists, psychiatrists, social workers, nurse practitioners, line nurses, peer support specialists, and people with lived experience and their loved ones. “We have a central clinical expert team made up of representation from all those voices, and we meet weekly.” She calls the team “the brain trust” of SMI Adviser.
When Dr. Cohen and child psychiatrist Dr. Tristan Gorrindo wrote the grant in 2018, they thought their continuing education audience would primarily be psychiatrists and nurses. However, since launching, they realized their largest audience is social workers. “Social workers need the most CE credits to keep their license and are critical to the care of those with SMI, so we quickly added social work and psychology credits,” she says.
This year, SMI Adviser is adding credits for pharmacists. In the United States, community pharmacists played an active and vital role during the Covid pandemic, not only through vaccination but also disease management and testing, filling gaps in primary care. Dr. Cohen believes the scope of their duties will likely continue to expand. “Historically, mental health systems have not collaborated enough with pharmacists or leveraged their expertise and proximity to people and communities,” she says. “Pharmacists are going to be key in mental health workforce development and retention.”
In many states, pharmacists can administer long-acting injectables, including antipsychotics. Also, a growing number of pharmacists are training to administer opioid antagonists to treat substance use dependence. “I think in the next one to three years, people who are stable on specific psychiatric medications will be able to get their injections at Walgreens, CVS, and Target,” says Dr. Cohen.
She and her team use data to drive SMI Adviser. A public-facing dashboard illustrates the initiative’s impact and provides a glimpse into the topics for which clinicians might need support. Unlike many other grants, SMI Adviser has the ability to adapt, allowing it to respond not only to analytics but also to current events. “In 2018, we laid out what we thought we should do, but we also left space to pivot,” she says. “That’s a new way of thinking about grant-supported research.”
During Covid, patients faced challenges accessing clozapine, an antipsychotic medication approved for schizophrenia. “It’s an extremely effective medication for treatment-resistant schizophrenia but underutilized in the U.S. compared to other countries,” says Dr. Cohen. Clozapine has been shown to protect against suicide for people with schizophrenia and schizoaffective disorder. A recently published autopsy study found that people taking clozapine were significantly less likely to have died by suicide than those who had been taking olanzapine.
Because of the risk of lowering white blood cells, specifically neutrophils, treatment with clozapine is restricted through Clozapine REMS (risk evaluation and mitigation strategies), an FDA drug safety program. However, due to changes in the Clozapine REMS system in November 2021, difficulties in the program’s rollout led health care professionals and patients to experience challenges with the program. This made it difficult for patients to access clozapine and led to interruptions in clozapine treatment in some patients.
“We, along with behavioral health organizations and other stakeholders, worked closely with the FDA and care providers on how to make the transition in terms of safety and user experience,” says Dr. Cohen. “We never predicted REMS would change, and suddenly we had an opportunity to influence people’s access to a really effective medication.” In response to the ongoing dialogue, the FDA delayed the full implementation of the Clozapine REMS program and extended an enforcement discretion allowing pharmacists to dispense clozapine without a REMS dispense authorization.
The grant allows for pivots, allowing SMI Adviser to respond to unforeseeable events and trends, such as Covid, and policy changes like 988, the Congress-designated number for mental health, substance use, and suicidal crises. Also, Dr. Cohen and her team react to data the initiative collects, such as which mental health professionals are using the tools and which aren’t, state by state. “I can also see who’s a repeat visitor, allowing us to continue growing our education and resources in a way that will be utilized,” she says. Quarter-by-quarter, she and her team strategize where to increase investment and effort and expand.
A common frustration for innovators is they can build an innovation, but that doesn’t mean people will use what they create. “We all say, ‘I can build it, but if no one’s going to come, what’s the point?’” asks Dr. Cohen. Fortunately, for SMI Adviser, the grant includes funding for engagement and marketing. “The requirements of the grant from SAMHSA specifically called for ‘an individual with marketing skills to engage practitioners.’” This has allowed the initiative to reach its intended audience and continue to hear from them about what is needed in the field. “In many ways, there’s an ongoing dialogue between SMI Adviser and the teams providing care for those with SMI.”
In April, the initiative hired a media company specializing in radio and podcasting for a three-month engagement campaign. “This will help expand our impact.”
The workforce shortage of psychiatrists and psychologists is also much on Dr. Cohen’s mind. In fact, the number of psychiatrists is projected to further decline as those retiring exceed those entering the field. She points out that even the rapid growth of psychiatric nurse practitioners and physician assistants isn’t enough to offset the plummet. The shortages are even more stark among those who work with children and adolescents. According to the American Academy of Child and Adolescent Psychiatry’s workforce maps, in Georgia and Louisiana, there are 8 and 10 child and adolescent psychiatrists per 100,000 children. “So what are we doing about it?” she asks. Some states, like Georgia, are trying to attract psychiatrists through local residency programs.
Dr. Mark Johnson, a psychiatrist at Gateway Behavioral Health in Georgia, which has a residency program, told WJCL Savannah that the best way to recruit and retain psychiatrists is to train them locally. “Half of specialists stay within 100 miles of where they train,” he said.
Dr. Cohen says collaborating with universities can also help recruit people into the field. She and her team soon hope to partner with medical and nursing schools and doctoral and masters level programs to help recruit people into the workforce and introduce them to people with lived experience and recovery-based, person-centered approaches. “We want to expose the next generation working in mental health care to people with lived experience and the promise of hope, empathy, and a passion for working in this field.”
She also wants to disrupt the still all too frequent notion that serious mental illness ends a person’s life as they know it. In 2022, Steve Miccio shared with #CrisisTalk that when he experienced his first manic episode, his care team made no mention of hope or recovery. “It was more about what was wrong with me and what medications would make me feel calmer.” He’s the CEO of People USA (formerly People, Inc.), a peer-led mental health crisis care provider.
Dr. Cohen points out that not only does a mental health care system without hope harm those who are diagnosed, but it also deters people from working in the field, hindering the growth and potential of the entire care system. “You want students to know that if they work with people experiencing serious mental illness, they have the potential to make a difference in their lives.
“We need to shift the focus to hope — that people can live quality lives when they have access to great treatment and care that feels like care.”
